COST EFFECTIVE SPECIALISED

HOSPITAL CAREIN AN ISLAND COMMUNITY

A case study on the Maltese Islands

Bad Hofgastein, Austria 28th September 2002

Dr John M. CACHIA

MALTA BASIC FACTS

•Centre of the Mediterranean Sea•391,415 inhabitants on 7 islands with an area of 316 km2

•1.2 million tourists annually of whom half from UK•Life expectancy(2000): 74.3 yr for males, 80.2 yr for females•Population growth rate 0.3%per annum•Infant mortality 5.9 per 1000 live births•Major causes of mortality and morbidity are

cardiovascular - hypertension, stroke, cardiac disease

cancer - lung, female breast, bowel

diabetes mellitus

IMPORTANT TRADITION IN MEDICINE AND HEALTH CARE

Knights Hospitallers of the Order of St. JohnNurse of the Mediterranean in Crimean WarMedical care services in WW1 and WW2Medical School which more than 300 years oldFamous Maltese doctors in Austria, UK, Italy, N. America,

and AustraliaBasic medical, nursing and paramedical training available

at the University of MaltaAll specialists trained in UK centres of excellence Doctors highly influential in Maltese society

BENEFITS TO POPULATION

Politicians compete to offer best servicesAwareness of limitations imposed by lack of financial

resourcesBest use of human resourcesHigh level of confidence in health care services as an

institution87% of Maltese are very satisfied or satisfied with public

health servicesHigh cost technology and specialised services became

available locally Wider spectrum of services not normally offered to a small catchment population of 390,000

LIST OF SERVICES CURRENTLY OFFERED

Neonatal Intensive Care Neurosurgery Burns Unit Spinal surgery Scoliosis surgery Renal transplant Angiography Angioplasty/stents Cardiac Surgery

Cobalt therapy Linear Accellerator Nuclear Medicine Laparoscopic Surgery Vitrectomy Cardiac Transplant Magnetic Resonance

Imaging

BALANCE

EFFECTIVE

CARE

QUALITY

CARE

BALANCE

DEVELOPcapital investment training recurrent expenditureavailability of

supplies

TRANSFERair transport sick patient stringent protocol limited family support subsistence/

accomodation

BILATERAL HEATH CARE AGREEMENT BETWEEN

MALTA AND UK

An example of how mutually beneficial is cross-border co-operation between countries

Number of patients treated in UK1990 - 2001

0

100

200

300

400

500

600

Patients

199019911992199319941995199619971998199920002001

COST OF CARE IN THE UK 1990-2001

in MALTESE LIRI(LM1=2.4euro)

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

Maltese Lri

199019911992199319941995199619971998199920002001

EFFECTS OF RESTRICTIVE POLICY

No service to complex casesEnormous waiting listsDeaths on the waiting listOver-medication instead of definitive careUnder-provision of careInequalityPressure on politician and service provider

CRITICAL SUCCESS FACTOR

the will of Maltese professionals of excellent calibre who made a name for themselves abroad to return home and

develop services locally

CARDIAC SURGERY

From 150 operations per annum(1995) to 300 operations per annum(2001)

Waiting list reduced from 18 months to 6 weeksNo distinction on the basis of severitySevere and urgent receive precedenceMortality less than 1.5% of operations8 cardiac transplants from 1996 of whom 6 are

alive to date

MRI EXAMINATIONS 1997-2001

0

500

1000

1500

2000

2500

3000

Examinations

19971998199920002001

APPLYING STANDARD EUROPEAN CRITERIA TO LOCAL SERVICE

PROVISION WITHOUT ANY RESTRICTIONS

Explosion of the number of patients requiring service and therefore waiting lists

Determination of new service levels and additional resource requirements

30% savings (Lm 510,000 per annum) in offering local cardiac surgery service

50% savings (Lm 216,000 per annum) in offering MRI services in public hospital

THE PRICE OF….

QUALITYTREATMENT AND CAREEQUITYEFFECTIVENESSAFFORDABILITY

CHALLENGES

Evolving epidemiology of diseaseIncreasing levels of care requirementsBuilding the necessary skills and

expertiseIntroducing sustainable new services

CASES CURRENTLY REFERRED ABROAD FOR TREATMENT

Bone marrow transplant Liver transplant Complex major spinal surgery Paediatric Cardiac Surgery Paediatric endocrinology, neurology, gastroenterologymaxillo-facial surgery Cochlear implant Siamese Twins!!!

DILEMMA….High recurrent and investment costLow patient volumeDeskilling of appointed staff

SOLUTION….Despite logistic constraints referral abroad

may be the ONLY option

OUR ROLEConstant vigilanceUpdated on technology developmentsShare experiencesIncrease awareness and resolveaddress inherent under-provision caused by

insularityadmit that some superspecialised services

will never be affordable to develop locally

HEALTH PROFESSIONALS and POLITICIANS have to...

come togetherunderstand each othercreate the right balance between costs and

accessibility

…to be of maximum benefit to our citizens who pay us to serve them.

THANK YOU FOR THE SPLENDID OPPORTUNITY TO ADDRESS THIS FORUM