Overcrowding at Mater Dei Hospital

As a researcher in family medicine, I am surprised each time the Health Division requests patients to stay away from the Accident and Emergency Department and directs them to visit their family doctor instead. This recommendation should not only be effective when there is an influenza epidemic (or is it pandemic?) but all year round.

Together with my colleagues Isabel Stabile, Anthony Mifsud and Michael A. Borg, we performed a review of all the published evidence on primary health care in 2009 and presented a copy to the Health Division when the proposed primary health care reform was still a priority. What we found was astounding.

The international literature provides substantial, authoritative and broadly accepted empirical evidence of the strong effects of primary care in reducing mortality and morbidity while containing costs, with improved patient satisfaction, across various health care systems and in various nations. Primary health care is at least as effective as secondary care in all diseases studied, with few exceptions (like diseases requiring highly technical care). A strong primary health care backbone evidently improves the outcome of the whole health care system while at the same time saving costs!

Health is better in areas with more primary care doctors. People who receive care from primary care doctors are healthier (correcting for previous disease). The core characteristics of primary health care are associated with better health in populations receiving such care.

Such evidence is supported by empirical data from local primary health care, which shows that, as in most of the developed world, 95 per cent of all Maltese health problems are cared for at primary as against secondary levels. Any small shift in this balance in favour of secondary care comes at high financial and health cost, besides risk of overload to hospitals. To prevent hospital deaths, it is far more cost effective to recruit family doctors than hospital specialists.

This has major relevance to what is happening now in Malta. A small increase in community illness has caused family doctors to refer more patients to hospital. If only a slightly larger proportion of the cases that family doctors usually solve now require a referral, this means the secondary care sector is consequently overloaded. For example, if family doctors only solve 94 per cent, rather than 95 per cent, of their cases, this means they will refer six per cent as against five per cent of their workload. Consequently, hospital workload increases by a massive 20 per cent! How can we avoid this? By helping family doctors to do more, with support in their difficult and crucial role.

Primary health care is authoritatively defined by the United States of America’s Institute of Medicine as a model of care based on first contact access, continuity of care, comprehensive care and coordination of all medical care by a primary health care provider (gate-keeper role). Today, in Malta, patients visiting a health centre do not see the same doctor each time and there is no continuity. Patients visiting a private family doctor have to be referred to hospital for even the most rudimentary investigations (simple blood tests, basic diagnostic interventions and the prescription of medicines for all chronic disease). Many other barriers exist to the provision of a European standard primary health care service.

Only very recently, the Health Division has given family doctors access to basic blood tests, which were denied in the past, while access to other basic medical tests such as ultrasound and prescription of anti-hypertensive medication remains restricted against consultant signature.

Malta’s primary health care is therefore not up to the most basic standards recommended by the WHO and the IOM.

Is it not time to provide the Maltese with state-of-the-art medical care, outside as well as inside hospital? Is it not time the Health Division appreciates the role of family doctors, not simply as stop-gaps when Mater Dei Hospital is full but as equal partners in its vision to deliver quality medical care to all Maltese?

In 2003, all family doctors in Malta became specialists at par with all other specialists, with equal rights and obligations. It is time for the Health Division to accept family doctors as equal partners to hospital specialists, as required by law, and give us equal access to tests, treatments and medicinal prescriptions. Then, and only then, can we provide accessible, continuous, comprehensive and coordinated quality primary medical care to the Maltese.

Ninety five per cent of Maltese medical problems are cared for by specialists in family medicine and the Maltese deserve nothing less but the best primary health care.

The quoted research was performed with colleagues in the Mediterranean Institute of Primary Care, which is based in Malta.

The author is reading family medicine and is visiting professor at the University of Ulster, Northern Ireland