Who’s the boss? | Martin Balzan

The John Dalli report on the state of affairs at Mater Dei Hospital drew negative, and at times furious, reactions from the majority of stakeholders in the health sector. Among the raucous chorus of disapproval, the Medical Association of Malta's Martin Balzan offered a docile yet stinging assessment.

Balzan admits that some of his own members thought his reaction was too timid, however he insists that it is not in his style to be abrasive or carry out personal attacks. The newly-appointed MAM secretary-general's first reaction was that the report was too negative and confrontational.

However, following health minister Godfrey Farrugia's efforts to distance himself from the report and the incessant criticism from the opposition and other unions, Balzan hands down a damning judgment of the situation.

"Who is running Mater Dei? Who is running the health sector? What are the government's policies?" Balzan asks.

In his report, Dalli warned that government must keep its distance from Mater Dei if it intends to have a sustainable general hospital. "Hands off... the responsibility of the hospital should be in the hands of its management," the former health minister and EU commissioner said.

Balzan was not impressed. "We have a health minister, but it is not clear who is in control. The minister is saying that he is in command, but in the report the other guy (John Dalli) is saying that he is ready to stay put, that the minister should vacate his office at Mater Dei and told politicians to keep their hands off hospital."

According to Balzan, this could signal a possible creation of an isolated body outside political control which is under somebody else's control. Warning that too many cooks spoil the broth, Balzan called on Prime Minister Joseph Muscat to eliminate the uncertainty and make it clear who is in control of the sector.

"We need to know who the boss is," Balzan says, who has been at the helm of MAM for the past six years and who was this week elected as secretary-general since the statute stipulates that the president cannot stay on for more than two successive terms.

I throw the question back at him: who is, in fact, the boss? A politician or a technocrat? Balzan believes that politicians are the ones elected and the popular vote legitimises their responsibilities in the health sector.

"People choose government and they trust politicians with administering the health sector. I do not agree that politicians should adopt a hands-off attitude. Whether they administer it well or not is another thing. But I do think that they should be involved because they were democratically elected to run the health sector, among other things. The people obviously expect that it be administered well. However, more importantly we need clarity on who is in control, for the benefit of everyone."

On Wednesday, health minister Godfrey Farrugia disassociated himself and government from the report, and said that the Dalli report does not reflect the government's position. Insisting that the Labour government has no position yet on the report, Farrugia announced that before taking a stand, a working group would be set up to analyse the report.

However, this will only add to the confusion, Balzan says. "This will only increase uncertainty. It's not normal, when a report is submitted to government it is only published if the administration endorses it. In my opinion the government erred.

Normally when a report is published it means that the government agrees with it. In this case, it seems that after its publication government either had second thoughts or it miscalculated. When a second report is being compiled it only nurtures confusion."

Balzan adds that "not only don't we know who is in charge, but neither do we have clear policies".

He calls on the government to come clean on who is in control, and what its policies are. This should not be done because it's in the association's interests, he says, but because it would benefit everyone, from the patients to the professionals rendering their services in the sector.

"I am worried because at this stage it's a mess. The sooner we get things sorted the better. To make things worse, this week the Chief Medical Officer's post was abolished. You could argue in favour or against this decision, however, at the moment we are operating without a Chief Medical Officer and without director-generals. One of the biggest problems we're facing is the lack of synchronisation between primary healthcare and the secondary and tertiary sectors."

He explains that the vacuum in the coordination between different sectors in health adds to the uncertainty.

"We do have a minister, but the minister needs officials to run the health sector. Therefore, I underline three major problems. Firstly, who is the boss? Is it the minister or John Dalli? Secondly, on which report shall we base our plans for the future? Thirdly, in the absence of a Chief Medical Officer and director generals who have yet to be appointed, how will medical services work in the interim period?"

Undoubtedly, Balzan's style contrasts sharply with that of Malta Union of Midwives and Nurses's Paul Pace, who lividly slated the report as "cowardly" and said he would not discuss the report with government unless it is either substantiated or revoked.

The minister announced that the working group that will analyse the Dalli report would be composed of independent members, some of them from outside the healthcare sector.

"MAM is not involved in any of these working groups. It's the government's prerogative. Secondly, when a report is being done over another report, its nothing but a damage limitation exercise. They are realising that the report was not well received and had a change of heart," Balzan says.

He adds that the association will never resort to carrying out personal attacks and does not rule out participating.

"We do not exclude anything. If we are invited to participate, it would be a MAM council decision. However, as a rule we stay away from sitting on government boards, because many a time, unions are involved in talks and in decision-making processes, however the government would still do as it pleases and then shift responsibility on the unions because they were part of the decision-making process."

Relations between MAM and MUMN have not always been rosy, however the Dalli report has united all stakeholders.

"In the past year, relations between both unions have improved. The report's confrontational language was not well received by our members and it has possibly created a common front, with Union Haddiema Maqghudin also declaring its agreement with our stand. So far, I believe that only the General Workers Union have not yet pronounced itself."

Yet, Balzan says that MAM will stand its ground irrespective of whether there is an alliance with other unions or not.

Turning to MAM's relationship with government, Balzan says that since taking office in March, relations have been good between both the minister and his experts.
"There's an open dialogue and the minister listens and understands. The Dalli report is a sore thumb in our relationship, because it has so far been cordial and constructive from both ends."

Balzan says that Dalli should have consulted all stakeholders before going public with the report. This would have softened the blow, Balzan says, adding that he believes John Dalli took up the job offer to rehabilitate himself following the debacle which saw him resign from his post as European Commissioner in 2012.

"I personally believe that he might see this as an opportunity to rehabilitate himself by doing something positive," Balzan says.

Asked to give a diagnosis of the health sector in Malta, Balzan says that on a whole Mater Dei and other institutions offer good quality service and people are satisfied.

"The existence of large waiting lists means that there is a demand for the health services on offer. The service is not perfect but its good. The problem lies in the fact that the demand is larger than the supply. There are two possible solutions: you can either rationalise the demand, by strengthening the interface between General Practitioners and hospital, while strengthening primary health care."

The Dalli report includes a recommendation to refuse self-referrals at the Mater Dei emergency department. However, Balzan believes that the people will oppose it, as did the minister. Moreover, it might create medical-legal problems. "Who is responsible? Is it the doctor or hospital if anything goes wrong? In principle we agree but it needs to be explored further."

Balzan also notes that the country does not afford to invest in new hospitals so the government must to maximise the current infrastructure and offer health services for longer hours. In the past few years, Balzan explains, the association agreed that medical professionals should be encouraged to work longer hours and have operating theatres functioning till 8pm.

"The tools are there but this administration has not implemented these measures. It will cost money, because it would require more doctors, more nurses and more beds."

Asked if the country has the human resources to implement such a measure, Balzan says that the amount of new nurses provides the necessary personnel.

He adds that similarly, doctors are committed to work for longer hours at the outpatients department, however the management "needs to act. It's either a problem of a lack of political direction or they are simply failing to act, or both".

The tools to resolve these problems exist but they will come at a cost, he adds, explaining that incentivising doctors to work between 4pm and 8pm would require improved working conditions.

Balzan puts the problem of out of stock medicines down to financial restrictions. "It's a financial problem, especially after October, the hospital runs out of money. It's a matter of financial sustainability. The blame is shifted to the management but it's mostly a budget problem. They never own up to it but they unfairly blame it on the management."

Yet, he does admit that there is room for improvement in the procurement process and floats a recommendation to have a unit set up to determine the real market price of medicines and medical equipment.
"Local bidders bid high and opting for the lowest offer will also land you a bad deal. There must be mechanism in the form of a network with other hospitals abroad to establish the real value of medicines and equipment."

He also argues that the country is facing a demographic crisis with growing number of foreigners residing in Malta and an ageing population set to increase the pressure on the healthcare services.

"We need a modelling system in which a scientific study would show how many doctors, nurses and beds will be needed in the coming years. The problem in the sector is that we have no adequate planning in place. Under (former PN health minister) Louis Deguara no planning was done at all. Long term planning only started under former ministers John Dalli and Joe Cassar and we're still trying to catch up."

Doctors in Malta are widely regarded as one of the most powerful lobbies, and while admitting that doctors have enough muscle to defend their interests, Balzan points out that over the last 15 years there has been no major industrial dispute or strike involving doctors.

Often doctors are accused of creating a backlog of appointments at Mater Dei to encourage patients to seek their services at private hospitals which would yield a bigger return in monetary terms.

"In recent years we have introduced what is known as the 'A contract', which bars doctors from holding a private practice. Out of the 130 or so consultants at Mater Dei around 60 doctors are on the A contract. Older doctors will find it hard to change their ways but more and more young doctors are taking up the contract."

He adds that MAM envisages a situation where up to half of the consultants practice exclusively at Mater Dei in the coming years and insists that the private sector plays an important role as it alleviates pressure on the state run services and grants patients an alternative choice.

MAM is ready to cooperate in any drive to reform the sector, Balzan says, citing the doctors' commitment to work longer hours as an example.

"When measures are implemented we will give our input to make sure they are successful and result in a better service for the patients. Once we are offered the right conditions to work in, the service will improve and the turnover will increase.

However, as soon as confrontation sneaks in and antagonism raises its head, it's a lose-lose situation for all."