Medical tourism to the rescue | Chris Fearne

Health has – paradoxically, in a sense – often proved a headache for Maltese governments in the past. And while it may not have been a major theme of the electoral campaign, there can be little doubt that disgruntlement with the national health service played a small part in the eventual outcome.

The Labour Opposition had capitalised on many past complaints – about waiting lists, out-of-stock medicines, staff shortages, union disputes, beds-in-corridors, the cost of building Mater Dei, etc/ – to eventually present itself as a panacea to all our health problems. Its electoral manifesto almost read like a medical prescription: ‘to be taken by the entire country, in a single large dose on March 13, 2013…’ Only it didn’t specify whether there would be any side-effects. 

Either way, expectations of an improvement in health service standards were understandably high: and while some areas do seem to have improved – stocks of medicines being the latest example – progress has not always been fast or rosy. Complaints can still be heard about waiting lists for certain operations, about overcrowding at Mater Dei… and ticking away in the background is the unspoken issue of long-term sustainability. 

Both parties are traditionally committed to preserving the NHS in its current, free-for-all form. Yet both have promised increasing the services provided for free across the board… while not raising taxes in any other area. We also know that Malta’s is an ageing population, and that demand for improved services is therefore set to increase exponentially. For the same reason, the fund which finances the entire sector is expected to shrink, even as medically-related expenses soar.

Clearly, there is a contradiction between the declared aims of the present government – i.e., to provide ‘more, better, free’ – and the underpinning economic reality staring us in the face. Something, somewhere, has got to give.

Or does it? Dr Chris Fearne, parliamentary secretary for health, almost radiates confidence that his government will deliver on its many health-related promises. In fact, he begins, it already has.

“Am I satisfied with the rate of progress? Yes. We have built up a good momentum, and many of the targets we set before the election are being reached. Take out-of-stock medicines, for instance. In the past it was an endemic problem, faced by all who depended on free medicines on the POYC (Pharmacy Of Your Choice) scheme. For the last four weeks, the rate of out-of-stock medicines has been zero. There may be shortages of individual medicines in future – if there is an international shortage, this would naturally affect us too – but not of the hundreds of medicines that up until two years ago were always out of stock. This was something we addressed from the first days we took over as government. It was one of my priorities as a parliamentary secretary. It was a management issue, really: placing orders on time, being aware when things are running out…”

Fearne however admits that not all problems are so easily resolved. “There are management issues, and then there are other issues related to resources. The problem is you have to have the resources to be able to manage them. And that’s one of the hurdles we face: a lack of resources, both human and in terms of facilities...”

He cites hospital beds as a prime example. “The situation in a nutshell is that we don’t have enough beds. Simple. The hospital [Mater Dei] is too small, and the number of acute beds available is insufficient for the needs of the country. One can manage the system better, yes, you can make arrangements here and there; but there is only a finite amount of management that can be done. At a certain point you have to increase the resources. The same applies to waiting lists: part of the problem is that we don’t have enough human resources and theatre space…”

The Health Ministry has recently outlined its general plans to address this shortcoming, and at a glance they seem to rely heavily on an input from the private sector. There has been talk of public-private partnerships to reduce waiting-lists, and this has inevitably raised concerns. Some fear the thin end of the wedge: that the use of private sector facilities for public health services will mark the start of a gradual privatisation process.  

Fearne however dismisses the notion with a solemn declaration that “the services we provide to Maltese and Gozitans will remain completely free for the patient. Whether we use Mater Dei, or a private hospital, the patient won’t pay a cent…”

He stresses that the partnerships are only intended as temporary, until human resources issues can be addressed. “The basic issue is that there is far greater demand for services than we are equipped to supply. In the longer term, we need to address the issue by providing better preventive care – this is an area where Malta has fallen behind over the years – so as to reduce the demand as much as possible. But in the short term we need to increase the supply. We have to invest in resources…”

From here, the decision is to either build up from scratch, or utilise what is already there. 

“What is it we lack? We have enough surgeons. But there is a lack of theatre space; of anaesthetists – and we are planning to hire more – and there is also a shortage of nurses. In the coming days we will be issuing a call for expressions of interest specifically for orthopaedic nurses, because that’s where the demand is highest. But in the meantime, what we lack can be made available by private hospitals: nurses, anaesthetists, and the use of operating theatres. Our surgeons will perform operations using the resources of the private sector…”

He specifies that we are talking primarily about hip- and knee-replacement operations. “The areas with waiting list problems are basically four: orthopaedics, cataracts, MRI [Magneting Resonance Imaging], and varicose veins… With cataracts, we’ve already managed to bring the list down. By the end of this year we will have reduced the waiting time to a maximum of four months, which is the international benchmark. When we started out, it was four years… “

Same goes for MRI: “From two years, they are down to not more than two months… a matter of weeks. As for varicose veins, we have introduced two new consultant surgeons, increased facilities and equipment; and this year, the waiting lists have been slashed from a number of years to a few months…”

Much of the improvement is down to management: operating theatres which had previously been used only in the mornings are now in use until 8pm and on weekends. The MRI scanner, he tells me, is now operational 22 hours a day. “So if you need an urgent MRI – or even if it’s not urgent – don’t be too surprised if they call for you at 3am. You have a choice: if you prefer you can wait another two months. But if like most people, you need it urgently, because you’re in pain or worried… you can do it at 3am. And I can assure you, the slots are being used…”

All this may be good news for those waiting for an operation, but it doesn’t really address the aforementioned concerns regarding the decision to rope in the private sector. After all, public and private health models operate very differently; and while one can easily see the benefits of partnership for government, the benefits for private companies are less clear. Given that they are, by definition, profit-oriented… how do they profit from the transaction?

“The idea for us is to avoid raising our own expenses; and for the private sector it is to make a profit. Our concept to achieve both goals is to rent hospital space and personnel from the private sector, and to utilise our own resources wherever possible. Our resources include surgeons, who in the private sector are the most expensive ‘assets’, so to speak. So it keeps our costs down. In cases of hip-replacement operations, we can also procure the necessary prosthesis for much cheaper than any private hospital, as we tend to buy in bulk. This way, the cost of renting the theatre, the anaesthetists and the nurses will end up being more or less the same as if we had done the operation at Mater Dei.”

The private sector, he goes on, also profits because “it is more efficient than government. This is true all over the world. Generally, if an operation costs us ‘X’ as a government health service, it would always cost a private hospital less. And if we use our own resources, the private hospital’s expenses will be less, too…”

This may well serve to keep the service free for the individual patient on any one service; but at the same time the costs will still indirectly be borne by the tax-payer anyway. And the Labour government is committed not only to retain the free health service, but also to enlarge it… without passing any additional burden onto the taxpayer. How achievable is this target in practice? 

“Our concept is that the health service has to find another source of revenue. We believe that this other source is medical tourism. We know there is a huge market for it, estimated at hundreds of millions. And Malta is ideally placed to tap into it. We have a good name: our doctors are known internationally to be of high calibre… we have already received requests from different companies, telling us they had a number of patients interested in coming to Malta for an operation. To date, however, we haven’t had the facilities. So we need to create the facilities to attract paying patients from abroad. This will provide the revenue needed to keep the service free…”

But that also means substantial investment… in other words, more expenditure. So we basically have to spend more in order to spend less?

“Yes. We estimate that, to upgrade existing hospitals, to improve the service for the Maltese, and to create excess facilities to use for medical tourism, we would need €200 million. That, incidentally, is where the figure comes from...”

The same figure is also being questioned by the Opposition as very specific, for an investment proposal that has yet to be actually launched. It has queried whether the investor has in fact already been chosen, and the deal already sealed…

Chris Fearne however insists that the sum represents the expected investment on the basis of the project’s worth. “As we speak the proposal is being drawn up. By the end of May the call will have closed, and only then we will know who the bidders are…”

The proposal itself is for a private investor to upgrade and extend three local hospitals. “St Luke’s, which has been out of use for nine years, badly needs an upgrade anyway. But we want to expand on it, so that a substantial part of it will be for local use, and the rest for medical tourism. Karin Grech Hospital will be upgraded, entirely for use by Maltese patients. We also need a new nursing school in St Luke’s, to address the human resources issues I mentioned earlier. And we need to upgrade and extend the Gozo General hospital. Lastly, a new medical school to be run by Barts, and a new centre for anatomical research. This is the vision…”

In the upgrading process, Fearne hopes to address a few other lacunae in the existing health service. “At present we do not have a rehab hospital. There is a ward in Karin Grech which we call a rehab hospital, but it’s mostly taken up by geriatric patients. Around 70 beds at Mater Dei are currently ‘blocked’, so to speak, by rehab patients because there’s nowhere else to send them. So in St Luke’s we will be establishing an 80-bed hospital dedicated solely to rehabilitation, offering physiotherapy, hydrotherapy, occupational therapy, and so on.”

A new dermatology hospital is also envisioned for St Luke’s, to replace the ward currently used at Boffa Hospital. And Karin Grech is to be enlarged with a 300-bed geriatric hospital. 

As for Gozo, the lynchpin of this vision is a new medical school to be run by Barts, and which will take in 300 paying students from all over the world. Why Barts in particular?

“An important consideration to attract paying customers is having a name. We already have a good reputation, both for our medical professionals and for our facilities. One of the things a patient would look for when choosing a hospital overseas is the name: if going to America, you might be looking at Mayo Clinic… if the problem concerns a child, you might want Great Ormond Street Hospital [in the UK]. That’s why we have entered into a partnership with Barts, which is a widely known name around the world. It can attract not only medical tourism, but also further investment in the sector…”

For Fearne this represents a win-win situation. “Barts pays rent to the investor, and charges international fees to 300 students. For us there are three spin-offs. One, we will have an international medical school of worldwide repute, and this will create post-graduate opportunities for research. Two, there will be 300 paying students from abroad, whose families will come and visit from time to time; this gives an economic boost to Gozo. Three, it gives us visibility in the health world across the globe. If you’re looking for treatment, and you hear ‘Barts Malta’, it’s automatically a name you can trust.”

Yet already there have been concerns expressed about how this investment might impact the existing medical education infrastructure. Unlike the local university, Barts can also offer international standard private sector wages. Some have predicted a brain drain, as lecturers at the Malta Medical School may be lured by better pay and conditions. 

Fearne disagrees. “Most of the lecturers at the new school will be brought over by Barts, from Queen Mary University. But yes, there will be opportunities for local lecturers. This is a good thing: we’re happy to be increasing opportunities. But we’re also negotiating with the University of Malta so that ideally, lecturers will already have a contract with the university. The university is happy with this. Many lecturers are what we refer to as T1 or T2: they are not full-timers. Most consultants, for instance, are T1. They only do two or three hours a week. This gives them ample opportunity to lecture elsewhere. We have discussed this with the Medical Association of Malta too, and they are on board with it: i.e., that Maltese specialists have enough time, if there is opportunity, to also give lectures at Barts without detracting from the education provided at the Malta Medical School.”

So he doesn’t share concerns that this may prove the first step towards a phasing out of the medical school? 

“On the contrary, we have even agreed with Barts that Mater Dei will remain the teaching hospital of Malta Medical School, while the new facilities in St Luke’s and Gozo will become the teaching hospital of the Barts campus. We envisage that there will be a cross-over, of ideas, of students. There will be an influx of lecturers, of different ideas. If anything, it should give a boost to medical education in Malta. It’s an exciting time to be a doctor or a medical student…”