Paying the price for free health | Joe Cassar

Just before it became fixated with divorce, the media was closely following the case of the Pakistani nurses employed to offset medical staff shortages. Soon it was revealed by the Labour Party that the first group of Pakistanis employed were allegedly being exploited by Chrism Services Ltd and was demanding a portion from their salary on top of a regular employment ‘fee’.

Sitting back on the dark, red leather couch of his office, Health Minister Joe Cassar says adamantly that the Health Department had never agreed with any companies to employ nurses. “The nurses had applied as individuals. Their alleged agreement with the third party was carried out behind everyone’s back. If, without us knowing, they signed up to this agreement, we cannot keep them from doing so. Since the agreement is illegal, it is up to the Police and the Director of the Employment and Industrial Relations to look into it.”

Cassar however adds that he had been informed that something wrong might be going on last year: “From the moment I heard that something fishy could be going on, I immediately contacted the police – back in March 2010, long before the media came out with it.”

So what types of investigations have been carried out since then?

“Ask the Police,” he replies point blank.

Does this mean that you are not following the case?

“It’s wrong to keep phoning up the police and asking them ‘are you following the case?’ when an investigation is ongoing,” Cassar answers simply.

But are you at least ensuring that no other nurses fall in the same trap?

“This is something they have been doing behind everyone’s back,” Cassar says, reiterating that once the Ministry was informed of the alleged irregularities it contacted the relevant authorities. “But there are things which could do more harm than good and one should be careful when talking about cases which are still being investigated by the police.”

Cassar adds that – since the normal procedure is for a person to apply individually – on the application form the Department saw the name of the individual and not the company’s: “This is something which no one seems to understand.”

He however also says that investigations are being carried out to look into who had submitted the nurses’ application forms.

Cassar stressed that “all nurses employed with me are regulated by law and everything is how it should be. What is happening outside that door of the hospital is something which is being investigated by the police – and it is something which they [Pakistani nurses] took upon themselves.”

I cannot help but wonder that if the agency guaranteed the job to the foreign nurses, then it was 100% sure that the nurses would be employed.

Cassar rubbishes this argument, saying that for a professional to be employed, one had to obtain a certification from the autonomous body which is the Midwifery and Nursing Council. “It is the council which licences you to work, following a long process which includes grading from interviews, experience, references, character etc.”

Another point of concern which is not going down well with the general public is the waiting lists and the overcrowding at Mater Dei Hospital. According to the Labour Party, notwithstanding the building of a state-of-the-art hospital, government has failed miserably in addressing this issue.

But Cassar doesn’t like talking about waiting ‘lists’. He prefers to call it waiting ‘time’. “By ‘lists’ one implies there is something static that has to end one day or another – something which, in medicine, is impossible.”

At the same time, he insists that “it is unacceptable to hear that people have to wait four or five years for a hip or knee replacement or cataracts operation. At the same time it is acceptable that people wait.”

Asked about what the government has done to address the problem, Cassar departs from the point that one must remember that Malta is an ageing population: “It is estimated that by 2020, a third of the population will be made up of elderly, meaning that the number of people on the waiting list will never be zero.”

He explained that the first way to tackle the list was to centralise the list. “With the old system, one person who’d go to three different doctors would appear as three individuals rather than one. With the new system, a doctor inputs the patient in the system and if that patient changes the doctor or seeks a second advice, his name would not be duplicated on the list.”

According to Cassar, this system has helped to reduce the waiting lists by 40%. He said that the second step was to increase the “throughput.” He added that whilst the number of operating theatres increased, government had also to look at increasing the staff:

“For every major operation, one needs five nurses, two doctors to operate and an anaesthist. Having said that, since 2007, we increased the throughput by 9,000 operations. We would not be honest if we do not look at the additional numbers on the waiting lists. But today we all know how much Mater Dei has improved over St Luke’s Hospital.”

Cassar said one should look at all aspects, from the day-to-day running of the hospital to the “hotel service” improvement. He added that this improvement led to more people choosing Mater Dei over private hospitals.

“To add insult to injury, insurances are urging people to make use of Mater Dei’s services rather than private services, and are paying them to do so. But until financial regulations in Malta change we can do nothing about it.”

Can the Ministry do something about it? Has it been in talks with the relevant authorities? Many have noted this problem, with some arguing that having people being paid to make use of public services, when those who cannot afford private healthcare have to wait behind others, is deeply unfair.

According to Cassar, the Health Ministry and the Finance Ministry have been discussing the issue, and discussions are still being carried out.

“But at the end of the day, the discussions are about regulations by the Malta Financial Services Authority (MFSA) and insurances. MFSA is an authority in its own right and it is the one which regulates insurances. We have also held discussion with the insurances – but things are moving slowly. I admit that it is a problem and that government should look into it.”

He adds that there are issues which have been going on for decades on end. “One cannot just wake up in the morning and expect changes. There are changes in the regulation which have to take their time and we have to lead MFSA to look into them.

“At the end of the day this is a domino effect,” he says. Cassar insists that as a Minister “I can only do so much.”

With more people making use of free health services, the sustainability of providing a service at no cost is bound to be a concern.

“There are various methods one can use to keep healthcare free of charge. We use the tax system where healthcare is directly funded from the peoples’ taxes. Other systems one could make use of include the creation of a specific fund for health.”

But wouldn’t the money still come from peoples’ taxes? What difference would it make? “Yes it would still come from the taxes, but it would be a fund specifically allocated for that purpose.”

Referring to the free medicines, he insists that for the service to remain sustainable, one cannot give everything for free. “If then one wants a system in which everyone would have their finger in the pie, the only system which could work is that of co-payment.”

Cassar says that when one argues that medicine abroad is cheaper than in Malta, it would be the result of the co-payment system. This system would increase the number of medicines provided by government, but each medicine would have a percentage the patient would have to pay.

“For example, the government would give a 100% reimbursement on a cancer medicine, but then would ask a 90% co-payment on Paracetamol and would give back the patient just 10% reimbursement.

“Though by this system government would be able to cover more medicines, government has not yet decided whether to implement this system and certainly, we have no intention of introducing it during this legislature.”

Would it help to decrease the prices of medicine if it was government who bought it directly from the supplier, rather than buying it from the distributor?

“First of all, this question should be directed to Chris Said and the Prime Minister, since the purchasing of medicines falls under their portfolio. However, the reality is that the whole methodology with which medicines are bought has nothing to do with the regularisation of prices.”

Cassar adds that at the same time, the government must be careful to which extent it should intervene in the regularisation of prices.

“If it enters the market, the government would end up competing directly with the suppliers.”

Cassar however notes that the methodology currently used by government to buy medicine is outdated. “First government issues a tender, then people apply (a process which takes some time) and once the tender is adjudicated, the medicine is bought. But since there’s the element of competition, usually someone appeals and government would not be able to buy from the distributor until that appeal is closed.

“At the same time, government cannot leave people without medicine; therefore a regulation exists where government can still buy a certain amount of medicine. However, the purchasing price is capped at €120,000 which means that barely enough medicine can be bought.”

According to Cassar, this system is forcing government’s medicine stock to run low, prompting them to redesign the methodology.

“The reform will regularise the contracts system and other new systems will be introduced, including reverse auction, electronic auctioning, framework agreements and so on.”

Cassar adds that another problem faced by importers is the lack of forecasting by on the part of government. “The reform includes the setting up of an agency which, amongst others, will provide forecasting of what medicine both Malta and Gozo will need.”

A different reform which we have long been hearing about but seems to have come to a halt is the primary health care reform.

Cassar claims that once the white paper had been issued for consultation, doctors divided themselves into four groups, all coming out with their different ideas. Once all 600 inputs had been collected, the data was gathered in a book and a systematic analysis was carried out. At this point, they realised that a huge divergence in ideas existed, and they “had to go back to the drawing board.”

When all input had been collected, the Ministry realised it had over 600 inputs from different doctors, so they gathered them in a book, carried out a systematic analysis and once they realised the huge divergences in ideas that existed, they “had to go back to the drawing board.”

“Meanwhile we realised that for the primary healthcare to reach its full potential, family doctors have to be connected, IT wise, with both health care centres and the hospitals.”

Cassar claims that one of the biggest problems faced by primary healthcare is “the huge lack of communication.”

According to Cassar, when patients “who are in great physical suffering”,  approach MPs and ask them to contact the surgeon at the hospital, they do so because “the family doctor would not have contacted the hospital himself.”

“When stopping from work and contacting the hospital, the doctor might be losing time, but it is something which should be done. Yet again, since they are suffering patients who need to find a way to end their suffering, I do not blame them for contacting us.”

Cassar reiterated that communication should flow from the patient to the doctor and from the doctor to the hospital.

“The way forward is communication, and government is going to facilitate this. If it is information technology that they need, then we will provide it.”

He added that doctors would then “have no excuse” of saying that they didn’t have the necessary X-rays or email available.

“The question will then have to go to the family doctors and see what they are going to give back to the Maltese population for us giving them all these things.”

Before the divorce referendum, another issue brewing in Parliament was the legalisation of the methodology used in in vitro fertilisation (IVF).

The last report published by the parliamentary select committee on assisted procreation called for the freezing of embryos. Despite this, the Health Minister has already declared himself against the freezing of embryos.

Select committee Chairman Jean Pierre Farrugia had said that the freezing of embryos would allow women to go through less cycles of stimulation, to produce enough ova (eggs) that can be fertilised artificially and then implanted. He had added that “freezing would also reduce mortality and morbidity caused to the woman by hormone stimulating therapy.”

But Cassar does not favour this methodology, and would rather see another method being implemented: oocyte vitrification.This method involves the freezing of oocytes (premature eggs) from women before fertilisation. “Why enter into a dilemma whether you should or should not freeze embryos when there is a system which provides for the same result, without having to freeze the embryos?”

At the same time, Cassar added that there could be instances where embryo freezing is justifiable “and we cannot do away with it.” He said that embryos should be frozen between the fertilisation and the implantation.

“If between the time you fertilise and the time you implant something drastic happens to the mother, or she decides she doesn’t want it, not freezing the embryo would be akin to performing an abortion.”

Cassar said the success rates of oocyte vitrification in the good centres “are as good as embryo freezing. One of the arguments against oocyte vitrification was that it stands nowhere compared to embryo freezing.”

“But a recent scientific study conducted in Italy showed that this was not a just claim,” he said, adding that oocyte vitrification over the years has improved.

Cassar said the Social Affair Committee is now looking into the whole issue of oocyte vitrification and are near the end of submitting their proposals back to the Cabinet. “There is no question that we need a law which regularises IVF,” he concluded, hoping it would soon come to pass.