Newly appointed Health Minister Joe Cassar says health reform was misunderstood and admits the document was too technical. Insisting health centres will remain free he says that changes will be made.

The primary health care reform proposals talk of a patient registration system. Today, any patient can decide not to continue visiting his family doctor for whatever reason without having to justify his actions. Doesn't the new scheme limit the patient's right to choose his own doctor in a free and unencumbered way?

This is not a reform of primary health care but a first step, the basis on which primary healthcare is built upon. Primary health means the patient receives care at his home and in his community. This reform is about the relationship between a patient and his doctor, what we refer to as continuity of care. It is not enough for any doctor to have access to your records.

Continuity of care means there is a relationship between the patient and the doctor. In medicine there are various conditions, especially chronic ones, where it would be beneficial if the doctor knew the patient in his entirety, including dietary habits, work practices, what worries the patient and how it affects him.

When a patient goes to a doctor who does not know him it is proven that the patient undergoes excessive medical tests and the chance of misdiagnosis increases.

Take, for example, a patient who gets a stomach ache whenever he is worried. The family doctor would know the patient suffered a stomach ache whenever he sat for exams, whenever he had problems at work or whenever he fought with his girlfriend, and would not recommend unnecessary tests.

You may have patients who feel uncomfortable going to the same family doctor. Take, for example, a 17-year-old who suspects a sexually transmitted disease and does not feel comfortable going to the family doctor with whom she was registered by her parents. What happens in such cases?

We made it crystal clear in the document that health centres will remain as they are today, with three or four open on a 24-hour basis. The walk-in concept will also be retained. You will still be able to walk into a health centre and get the treatment you need. It is very unfortunate this was spun out of proportion for political reasons.

Research shows that in cases involving sexually transmitted diseases people normally go to the genitourinary clinic in Boffa Hospital or to health centres, so the issue you raise does not worry me that much.

Under the new system each individual would be registered with a family doctor so a 16-year old has the right to be registered with any family doctor she chooses. The document also makes it clear that patients retain the right to seek a second, third or more opinions on their medical condition.

Today, a patient can choose not to call the family doctor and opt for somebody else without having to justify his actions to the doctor.

That is bad for the patient. I have no problem with somebody seeking a second or third opinion and it is important patients come clean with their doctor on the matter. If the family doctor is taken aback then he has a problem because patients have every right to seek a second opinion. However, it is important that the family doctor knows about this since it would prevent double or triple testing, and more importantly, it prevents duplication of medication.

Around 70 per cent of people, even pink and yellow card holders, visit their family doctor, but when they come to the prescription they go to the polyclinic to get it for free. When they go to the health centres they do not find the same doctor and it has also become a bad habit for people to go with prescriptions of other relatives and neighbours.

The doctor just issues the prescriptions without carrying out a basic check-up to determine whether the patient still needs the medicine. What we want is for the prescription to remain free but for people to have to go to their family doctor, who would be able to conduct a check-up. We are saying that pink and yellow card holders would have their private doctor visit subsidised as well. It was totally spun out of proportion when people said the reform would introduce a fee.

Jean Pierre Farrugia, a doctor and your colleague in Parliament, has said that forcing people to go to their private doctor for referral to specialists is akin to introducing a fee where there was none.

People did not understand a very simple statement: this is just a consultation document. The government wanted people to study it, read it and get back with feedback.

It seems there were a lot of people who did not understand it.

Unfortunately, there were a lot of people who did not understand it but when we sat down with them on a one-to-one basis they understood.

We have realised that one of the things that must change is patient registration with health centre doctors. People should have the possibility of registering with a doctor from a health centre. This is one of the issues that cropped up during the consultation process.

Another proposal that will change is the concept of having family doctors operating on a 24-hour, seven day a week basis. The proposal just outlines the concept but we know it is impossible for any doctor to be available all the time for his patients.

There was a misconception that a patient registered with a doctor would have the right to sue his doctor if the doctor was unavailable, for example at 2 a.m. This is not on. Under the new system the patient could still walk into a health centre and receive medical care for free just like things are today.

Another parliamentary colleague, Louis Deguara, has said the system is ideal but very difficult to put into practice. He also said it was a skeleton document without details.

He was right. We intended it to be a skeleton document to be able to beef it up with help from people and doctors. The consultation will end in the first week of March and we will produce a second, more detailed document after evaluating all the criticism and suggestions received. The new document will also come out with a road map.

There was a misconception that the reform would be implemented at one go. No reform was ever implemented in such a manner. The document was only talking about principles. Many people feared that this was the document. They did not realise it was a consultation final document. Today various organisations have understood this.

Will it still be possible under the reform to walk into a health centre and seek treatment for free?

Yes, it will remain the same as it is today.

So what is the point of having a patient registration system if it will still be possible to walk into a health centre?

The aim is to have a strong patient-doctor relationship, which would also help us in prevention campaigns. It will help us have accurate statistics on various ailments. Family doctors are specialists in their own right.

There is a register for family doctors. They are useful when it comes to health prevention and promotion.

If we were to introduce a programme for cervical screening, it is not something you can organise for the masses because women prefer going to the doctor of their choice. If we do not have robust programmes of health prevention and promotion we will continue to face the problems we have today, such as obesity, which will lead to diabetes, heart disease and so on.

Does the reform put the patient at its centre or does it give doctors more power?

It gives a lot of power to the patient and puts the patient exactly where he should be: at the centre. The patient has the right to change the doctor and this is what is probably scaring some doctors.

Dr Farrugia said he was convinced doctors would raise their fees under the new scheme, more so when government declared it would allow the free market to determine the price they charged for their service.

This was a concern raised by others as well. I believe that Dr Farrugia's criticism and concerns were genuine and they will help us in our job.

I have always stated it is healthy to have people like Dr Farrugia who voice their concerns. I do not know why in this polarised world we cannot accept a situation where somebody does not agree with us.

But Dr Farrugia said he would not vote for such a reform. You do not have a parliamentary majority for this reform.

Yes, and it is good that he expressed himself. I want to make it clear though that a reform like this does not require a vote in Parliament. Patient registration does not require a parliamentary vote.

Is there any intention of going to Parliament with this reform?

No, it is not a Bill. We have conducted a wide discussion that was extended from January to the first week of March. After this phase we will stop and reflect on all the feedback received to start putting meat to the bones. However, we have to understand that what Dr Farrugia said was genuine and we will be taking his criticism seriously.

The pensioners' association has also expressed concern over what could happen to doctors' fees. There may be doctors who would want to abuse this scheme and we have to address this genuine concern.

How will you address it?

We cannot address it by saying that if the criticism is correct we should freeze doctors' fees. We have to ponder on it, think about the financial consequences on the country, think of how existing laws should be changed like the Medical and Kindred Professions Act, which prevents undercutting and not overcharging.

A freeze has consequences in its own right. However, I believe people are intelligent enough, and when they realise a doctor is abusing the system and overcharging them they would go to another doctor.

It is uncomfortable for people to confront their doctor.

They do not have to confront their doctor. If you want to ditch your doctor all you have to do is phone up the registrar and inform him you are registering with another doctor instead...

And your previous doctor would know you have ditched him.

So what? The doctor would have to examine his conscience. What can he do to the patient? This happens even today.

However, today the doctor would not know if you went to another one.

They do know. Malta is too small not to know. If I had a regular patient coming to see me and the patient fails to turn up for two months running, do you think I would not know the patient went to somebody else? It is obvious and stands to reason that this happens.

However, I believe there is genuine concern but it should not be spun out of proportion, because if we do spin it we will lose focus of what the reform is all about.

Did Dr Farrugia spin it out of proportion?

No, he did not. Others did. Dr Farrugia's criticism was evaluated seriously and it helped us a lot. The media used him to create the perception there was a conflict between us.

He wasn't the only one to criticise the reform. There was also the former parliamentary secretary Frans Agius.

I talked with Dr Agius and I can assure you our relations are good. We discussed the reform, and in principle Dr Agius and Dr Deguara agreed with it. Let us not blow things out of proportion.

Dr Agius said the details had to be worked out because there were certain aspects in the details which were worrying him. I understand him, but the reality is there are no details yet. I believe we should look at it as it is: a consultation document.

Some people have highlighted negative things, others positive things, and we will now put everything in a balance and come out with a beefed-up document. This is consistency within the government. This is how we have always operated whenever undertaking reforms. They all started with a consultation document that was eventually changed.

You are constantly saying the reform was misunderstood. What went wrong if so many people misunderstood it?

If I had to look back at the document I would say it was too technical and it did not give specific examples. This left people in limbo.

The other reality is we were carrying out educational campaigns on television and for some reason the Broadcasting Authority stopped us because they felt they were political.

Why carry out an education campaign on a document which you admit will change radically at a later stage?

People have to understand what the document is about to give us feedback and help us change it.

The problem of lack of beds at Mater Dei Hospital has come to the fore again this winter with patients having to be placed in corridors. A woman gave birth in a corridor and another patient was given CPR. Aren't these situations degrading patients' dignity?

The problem of overcrowding needs to be looked at from a wider perspective. Inadequate primary health care means more people end up using the hospital.

A second problem is the lack of resources to provide rehabilitation at a community level, which means people stay for a longer period at hospital. We also have to build a rehabilitation hospital to make sure Mater Dei remains a tertiary health care facility.

Resolving these three aspects should help tackle the problem of overcrowding. The lack of proper treatment at primary level means that even hospital's outpatient clinics are inundated with cases that can otherwise be treated elsewhere.

These are long-term solutions of little consolation to those patients at Mater Dei who are stuck in a bed in a corridor. This problem seems to erupt every winter. Are there any contingency plans?

It is not possible for a new rehabilitation hospital to be built by next winter. However, we have been tackling the issue on a contingency level.

Whatever happens to the patient registration scheme we at least want to have continuity of records by digitalising X-rays and blood tests. This would minimise the need for people to have to go to hospital since doctors at health centres would have access to these records.

We are also seriously planning and working on the plans for a rehabilitation hospital.

What are the plans?

I will not divulge the plans because it is premature but we are working on them.

But it will take years to build.

It will not take years to build. Furthermore, more community centres for the elderly are being planned and health centres will be strengthened. It does not make sense that somebody with a sprained ankle who goes to a polyclinic is sent to Mater Dei for an X-ray.

With digitalisation an X-ray could be taken at the health centre and a specialised doctor at Mater Dei will be able to view it. This will prevent certain patients going to Mater Dei. It will take some time to have it all in place but we are working on it.

Until all this falls into place people will be cared for in corridors.

We are working on it. Digitisation of records and upgrading of health centres do not take years. Building a rehabilitation hospital does not have to take years. It is a complex situation which we are working on and it will take a lot of people, doctors and nurses, working together and making an extra effort to solve.

Watch excerpts of the interview on timesofmalta.com.

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