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Malta
General practice/family medicine in Malta:radical change by 2000?

Dr Philip Sciortino 

The Maltese islands consist of Malta, Gozo and Comino, the three of which are inhabited and two uninhabited rocky islands, Cominotto and Filfla. They occupy an area of 31 6 square kilometres, with Malta the largest island at 27 kilometres long, 14 kilometres wide and lays 96 kilometres south of Sicily. There are about 370,000 inhabitants. Infant mortality for 1995 was 8.9/1000 births and life expectancy was 74.88 years for men and 79.49 years for women. Recurrent public health expenditure in 1996 amounted to about Lm 40,000,000 which is 3.3 per cent of Gross Domestic Product (GDP).The number of medical practitioners registered in Malta is around 1,150. This includes 60 foreign physicians/surgeons engaged by the government to occupy certain posts with the Department of Health. Eighty-one per cent of listed doctors are males and 19 per cent are females. Sixty-one per cent possess a first medical degree while 39 per cent have a postgraduate qualification. One thousand and twenty doctors are registered as Malta residents and 130 as overseas residents. Of the 1020 doctors in Malta, 560 are employed by the government. The rest are either in private practice or retired.It is estimated that the total number of doctors engaged in general practice/family medicine is in the region of 260, of which 90 are government employed while the rest practice as solo private practitioners.

Public primary healthcare
Until 1977 GP/FD services in Malta were provided by self-employed solo private medical practitioners and by around 50 salaried government employed District Medical Officers (DMOs)The latter offered free GP/FD services to a section of the population with low income. Each DM0 was responsible for patients within a defined geographical area, attended to patients in government dispensaries known as Bereg and at patients' homes when so required. DMOs were allowed the private practice of their profession when off duty. The posts of DM0 were abolished as a result of a medical dispute in 1977 and in 1979 the first government health centres made their appearance.Today GP/FD services in Malta are provided by about 170 self-employed solo private medical practitioners and by about 90 salaried government employed doctors who run eight health centres over the island. There is no patient registration in Malta and GPs/FDs have no formal patient lists. Patients are free to access any doctor or specialist whenever they require medical attention.It is estimated that 20 per cent of the population always seek medical attention from Health Centres and 20 per cent always go to private GPs/FDs. The remaining 60 per cent make use of both services. It can be said that the workload is equally shared by the public and private sector

Health centres provide the following services:

Family doctor service
This consists of GP/FD services and emergency services to patients attending these centres. Health centre doctors also perform house visits when the need arises. The service runs on a 24-hour basis, seven days a week. Patients walk into the centre without appointment to see whichever doctor is available at the time. There is little to stop patients from attending at all hours for trivialities. The present system does not encourage the formation of,proper doctor-patient relationship or continuity of care.In addition to health centres, there are 45 government dispensaries in various towns and villages, this being a remnant of pre-1977 DM0 service. They are open for sessions of one to two hours on weekdays and are mostly used by patients requiring repeat prescriptions or medical certificates. Currently doctors and nurses are deployed during every session in these dispensaries.

Other services available through health centres;
specialist services: health centres cater for specialist clinics in internal medicine, diabetes, psychiatry, ophthalmology, obstetrics, gynaecology, paediatrics and dentistry;

paramedical services: these include nursing, midwifery, pharmacy, physiotherapy, radiography, podology, speech therapy, optometry and laboratory services;

preventative medicine: these include immunisation, well baby clinics, ante natal care, cervical smears, glaucoma screening, smoking cessation clinics and weight control clinics. The morale of health centre doctors is low. They are on a salary and most of them feel it is necessary to engage in private practice or as company medical officers while off duty in an effort to supplement their income. This means they have to work a substantial number of extra hours per week in addition to the time they work in health centres. Furthermore, they are faced with an ever increasing work load in addition to unlimited access by patients. The full complement of 90 health centre doctors is rarely reached because doctors are either resigning from their posts or leaving long term temporarily hoping to establish themselves in private practice.Obtaining the highest grades can enter the Medical School of the University of Malta which takes about bO students every two years. Basic medical education takes five years following which medical graduates are obliged to work for two years with the government.Family medicine is not considered as a speciality and there is no Department of Family Medicine in the Medical Faculty. There is a post of one part-time lecturer in family medicine who delivers a number of lectures in general practice and encourages undergraduates to participate in the student-GP attachment scheme. Specific (vocational) training in general practice does not exist. The Malta College of Family Doctors is striving to elevate family medicine to a speciality and to this end has produced a document proposing a training scheme of three years duration for specialists in family medicine. The college also runs a programme of continuing medical education consisting of a three day meeting held in each term of the academic year.

The GP/FD and other professionals
The GP/FD in Malta does not act as a gatekeeper having the responsibility to manage all health problems of patients either at primary care level or by referral to specialists or hospitals. Patients have direct access to all specialists, especially in private practice. Most specialists hold appointments within state hospitals and also operate their own private practices. Patients seeking specialist medical care are either referred by their GP/FD or can go directly to specialists.With an ever increasing number of medical graduates, more doctors are specialising and the GP/FD has to compete with an increasing number of specialists. The number of paramedics such as psychologists, physiotherapists, chiropractors, pharmacists, nutritionists, etc, is also on the increase. Patients again have a tendency to access these professionals directly giving rise to more competition for the GP/FD.Increasing specialisation may easily lead to fragmentation of healthcare which is a threat to integrated, co-ordinatc'd and continued care resulting with ineffective and inefficient use of resources.

Private primary healthcare
There are about 170 self-employed solo GPs/FDs whose services are affordable to the majority of people. Private GPs/FDs rely exclusively on fees for items of service paid directly by patients. Although there is no formal registration private GPs/FDs have a core of patients that consult them most of the time for all their health needs.Most private GPs/FDs run a single handed practice without any secretarial or nursing support. In spite of their limitations, these practitioners provide their patients with an easily accessible, continuous, person orientated healthcare which integrates curative and rehabilitative care, health promotion and disease prevention. Health problems of individuals and families are considered holistically from the physical, psychological and social perspective. Although not forming part of a multidisciplinary team, the private GP/FD assumes the responsibility to coordinate referrals to specialists and hospitals when appropriate and becomes the patients' advocate on all health matters.

The future

The status of General Practice/Family Medicine (GF/FM) in Malta is still nowhere near the standing it enjoys in many european countries. It can be said that neither the University of Malta nor successive governments have really taken any substantial steps aimed at improving the position of GP/FM in Malta.While the Medical Association of Malta looks mostly after the political interests of GPs/FDs, the more recently founded Malta College of Family Doctors is an academic body concerned with improving the status of GP/FM and acts as a pressure group to influence the development of undergraduate, post-graduate and continuing medical education in addition to promoting quality assurance and research.The future of GP/FM lies firstly with the Government, the University and the medical profession giving recognition to the importance of developing structures to generate appropriately qualified GPs/FDs who are properly trained to meet the challenges posed by Target 28 of the World Health Organization (WHO) which states that, 'By the year 2000, primary healthrare in all Member States should meet the basic health needs of the population by providing a wide range of health promotive, curative, rehabilitative and supportive services and by actively supporting self-help activities of individuals, families and groups.'Secondly it depends on the disposition of the medical profession to persist with its efforts to persuade policy makers, decision makers, politicians and the general public that, as stated by WHO in its 'Health for all Policy for Europe', healthcare systems should be founded on primary healthcare. The medical profession must be clear in stating the changes necessary to provide a cost-effective, equitable, accessible and comprehensive system of primary healthcare embracing the principles as stated in the proposed WHO Charter for general practice family medicine in Europe and which should lead the country to the next millennium.process of recording the applications. The Council has received support from all the specialist advisory bodies in establishing criteria and procedures to deal with these applications. Specialist registration is a voluntary, not an obligatory procedure, but it seems likely that employers will increasingly seek evidence of specialist registration from candidates for career posts.

Workload and workforce
There are 1,647 doctors in the GMS Scheme. There are 600 doctors working in private practice. The current annual requirement of new entrants to the existing GMS Scheme to cover death, retirement and service expansion is only 25 to 30 per annum. There are 55 graduates from the specific training schemes annually. The only method of entry to the GMS Scheme is by interview for an advertised post, or as an 'Assistant with a View'. This is now proving unacceptable to the excess 25 to 30 specifically trained doctors annually coming off the training schemes who do not succeed in getting a GMS position in a location suitable to them, usually where they have set up in private practice. This annual excess of suitably qualified doctors are seeking an 'open access' system to GMS posts.The IMO's position is that if such were allowed and accepted, there would be a multiplicity of smaller lists (current average GMS is 720 patients). This would have a depressant effect on average GMS incomes and would lead to a lack of opportunity for ordered development in genera] practice. An 'open entry' system into the GMS could only be considered if GMS eligibility was extended and its introduction was part of an overall workforce plan for general practice. This plan would take into account the viability of practices and the planned distribution of lists, while maintaining the essential element of choice for the patient. An 'open-entry' system would have to take into account the important question of the number of medical school graduates and the number of specifically trained graduates to be produced each year keeping in mind the lack of European consensus on strict 'numerous clauses' in other Member States.The general practitioner in Ireland is regarded as the doctor a patient sees in the first instance for medical treatment and advice. The GP treats individuals and their families in context and provides continuity of care. The GP is increasingly moving from treating acute episodic illnesses to more active management of many chronic illnesses. The recent National Survey 1996 showed the high workload the average doctor carries. This workload is steadily increasing. This issue of increasing workload and future workforce planning must go hand in hand. General practice is now becoming architecturally visible, the staffing and equipment levels are improving, but the resourcing (between private and state) is still inadequate to provide a modern competent service. The lack of full patient registration is hindering progress, especially any proposed National Cancer Screening Programmes. The skills mix required will put intolerable pressure on single handed doctors practising alone. The provision of an (increasingly demanding) out-of-hours service after a hard days work has become an unacceptable strain for many. New working methods will need to be piloted to alleviate this strain. For those without access to 'doctor on call' services, the United Kingdom (UK) model of cooperatives, providing out of hour cover from a central base with agreed community guidelines for home visits, may have some benefit for many rural doctors. Others may be happy to continue with rota arrangements.

 

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