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Too many doctors in the house

The problem of hospital overcrowding was frequently in the headlines over the past weeks and a task force has now been set up to focus on the issue. Bertrand Borg discussed the problem with Health Minister Joseph Cassar.

Hospital overcrowding Patients are lying in beds in hospital corridors...

A union is part of politics but politics with a small ‘p’ because it’s not a political party

Our emergency room is overcrowded. It’s not an everyday situation, but when I say that, people belittle me. What concerns me is that there is a good chunk of vociferous people in Malta who comment online and that fraction of society dictates, in a very subjective way, what the issue is.

Do you feel the issue is being distorted?

The patients we see on TV and videos lining corridors have all been admitted. They aren’t waiting to see a doctor. Ninety-five per cent of these people are elderly. A good number of them come from homes for senior citizens and they come at weekends.

That’s still a problem.

I know there’s a problem. But saying there’s a problem and then getting [Malta Union of Midwives and Nurses President] Paul Pace flaunting the fact that there’s a problem is beyond me. We need to analyse the problem and come up with specific recommendations.

Hence the taskforce?

The taskforce we announced recently wasn’t the first taskforce we’ve had. There’s been an inter-ministerial taskforce made up of the Office of the Prime Minister, my ministry, the finance ministry and the previous ministry of social policy.

This latest taskforce is looking into these recommendations and making them operational. It is the workers on the ground who must make this happen.

Isn’t the taskforce a sign of a lack of confidence in the way Mater Dei is being run?

Not at all. If anything, it’s more confidence because management is seated at a table, talking to union representatives to solve the problem together. I have full confidence in Mater Dei’s management.

What about the MUMN?

I will only say one thing about the MUMN: Although it officially represents all the nurses in Malta, I can say, hand on heart, that there are so many nurses meeting me and dissociating themselves from its current administration.

Are you saying the MUMN’s administration has lost legitimacy?

No. If only 30 per cent of an electorate goes out to vote, then the winner is legitimately elected. But 70 per cent haven’t voted and have to sit with the issue. I’m making up the numbers, but this is my sense of what’s happening with the MUMN.

MUMN president Paul Pace would probably disagree.

The risk of saying this is that Mr Pace will now have an extraordinary general meeting with his 100 to 200 close delegates who will wave his flag and give him their support.

That sounds very similar to a bigger political issue we had nationally...

Yes, of course. A union is part of politics. Politics with a small ‘p’, because it’s not a political party. Though sometimes I wonder.

How so?

It’s very interesting the way a union says something, and the following day the opposition says the exact same thing. Then another union says something, but the opposition doesn’t repeat that.

So you suspect collaboration between the MUMN and opposition?

I will not say anything.

But you’ve noted several coincidences.

As a psychiatrist, I’ve learnt to observe. And when you observe the MUMN issuing a statement and the opposition holding a press conference the next day saying exactly the same thing... let’s say it’s a coincidence.

Can you work with the MUMN’s current administration?

I’ve worked with the MUMN for a long time. What gets to me is having an informal meeting with the MUMN now, and then seeing a statement which is the complete opposite of what was discussed five hours later.

So you can’t work with it.

I can work with everyone. The problem is I don’t know where I stand.

Can the taskforce work without the MUMN’s participation?

No. Unfortunately I think the MUMN has boundary issues. Its boundaries are marred when it comes to management and union issues. The MUMN is one of the few unions which expects to be consulted by management each and every time a decision is taken.

The moment a decision or even a thought comes to management, they’re forced toconsult the MUMN.

So they’re being held hostage by the MUMN?

Yes.

Would it be fair to call primary healthcare inadequate?

No, I don’t it’s a fair word. I think it’s all part of the same equation.

Isn’t it inadequate if people keep going directly to Mater Dei emergency even though they don’t need to?

One has to understand that going to an emergency room is in itself mind-settling. If something happens to you, you go straight to the top. This is our culture.

Is it a culture which can be shifted in one way or another?

It has to be shifted. What people don’t understand is that teaching hospitals all over the world – in the US, UK or Malta – are run by junior doctors during the evenings and nights.

Doctors at our health centres actually have more experience than junior doctors at hospital. The only difference is that at hospital, doctors can refer you to specialists if needed.

So what happens now?

People need to understand this. They need to first go to health centres before going to hospital. And we’re going to equip health centres so that they can get all the care they need there.

One option would be to introduce a nominal fee to enter hospital emergency unless you’ve been referred.

No, you couldn’t do that. That’s a very ­dangerous tool and politically I don’t think anybody is even going to think about it.

So is primary healthcare going to be stepped up?

Of course. For instance, we’re going to outsource radiological services to the private sector. We’ll be starting with our three round-the-clock health centres in Mosta, Paola and Floriana.

What does that mean in practice?

It means that if you fall, hurt your arm and go to Paola health centre in the evening, instead of being referred to hospital, your digitalised X-Ray can be electronically sent to Mater Dei and seen immediately from there.

What about the problem with elderlyadmissions?

We’ve also realised that a lot of elderly people turn up in hospital at weekends. So we’re going to issue a call for applications for GP group practices to take care of specific homes. That way, residents at elderly homes will have their own teams of doctors.

And at Mater Dei?

We’re trying to increase the number of senior staff present in casualty 24/7. That will make a difference when assessing patients and deciding to tell people that they can go home.

We’ll soon be opening another 16-bed holding bay. The tenders have been awarded, work will soon start and I expect it to be completed within three months.

What needs to change there?

Professionals need to start changing their work processes, which they’ve been using for at least 30 years. This is the real problem at Mater Dei Hospital. We’ve not been flexible to change our work practices.

What sort of work practices?

For instance, why do people have to come into hospital at 8 a.m. for an operation that’s happening the next day, when the bed isn’t available before 4 p.m.? That same bed could be utilised by day care patients.

We have a number of patients who are discharged at 9 a.m. but who for some odd reason go home at 5 p.m. You could use that bed for a day care patient who needs the bed throughout the day but will be discharged at 5 p.m.

How do you change these practices?

Whatever unions say, the only way they will change their practices is if government provides money. No doctor wants to work in outpatients in the afternoon, because they want to work in their private practices.

Nurses are the same. They don’t want to work afternoons because they have families. As though you or I don’t have families too.

No doctor wants to work in outpatients in the afternoon because they want to work in their private practice

But this is a problem that’s been a long time coming.

Yes, and we’ve been working at changing these practices for some time. But when push comes to shove, they all say “Give us the cash, and we’ll change work practices.” It’s not on.

What about cultural changes?

Abroad, even for major operations, patients are admitted into hospital on the day of their operation. You’ll have exceptions, but the average person doesn’t need to come to hospital beforehand. They can stay at home.

Another thing that needs to change is that people need to trust doctors more. Ifyour doctor tells you that your father or mother can go home, you have to trust them. If a person is discharged at 9 a.m., their relatives can’t just decide to wait till 5.15 p.m. to collect them from hospital, because in the meantime someone else is waiting for a bed.

Why has it taken so long for the government to tackle these problems?

Because it doesn’t depend on the government; it depends on individuals. I’ve set up a discharge lounge. It could be used much better. The Labour Party went out to flaunt the fact that it didn’t work. It would have been better for them to speak to workers and the public and encourage them to use it. I am willing to assume responsibility, but responsibility is also collective.

Would we have the current problem if Mater Dei didn’t have fewer hospital beds than St Luke’s?

Both parties talk of sustainability, but I don’t think the PL knows what the word means. Are we talking of solving the problem by adding beds but not looking at work practices? Do you know how much a hospital bed costs?

Why not bring in foreign nurses?

Six-hundred foreign nurses applied to work in Malta. They were dragged through a mangled nursing council process which is closely related to the MUMN. It took some of these nurses two years – two years – to get their warrant. And from 600 applicants, we ended up with 34 nurses.

How optimistic are you that we won’t be in the same situation in 12 months’ time?

If everyone assumes responsibility and makes the necessary changes, I’m optimistic. Taxpayers’ money needs to be well spent. And if changing work practices will make better use of that money, then the practice will have to change.

So the raw material – nurses, doctors, beds – to solve the problem is there?

Yes, definitely. But we need to manage our resources well. And that includes politicians from both parties – they need to stop trying to play doctor and send me SMSs or e-mails asking me to keep patients even though they’ve been discharged.

How would you grade the situation in Mater Dei out of 10?

In the hospital in general, I’d say 8.5. In the emergency room, I’d give it a 6.5.

And healthcare in the country?

I’m not the judge of it, the whole world or WHO is the judge of it. Like I said, social media dictates a lot of things. But social media is not representative of the whole nation.

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