There are many aspects relating to our profession that lead to varying degrees of inner and outer conflict. These have to be looked at objectively, rationalised and managed appropriately so that they inflict the least possible damage to us, to those around us and particularly to the individuals whose wellbeing is our avowed quest.peer-reviewe

Fenech, Albert

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Malta Medical Journal    Volume 17   Issue 02   July 2005 7Guest EditorialSense and SensibilitiesAlbert FenechThere are many aspects relating to our profession that leadto varying degrees of inner and outer conflict. These have to belooked at objectively, rationalised and managed appropriatelyso that they inflict the least possible damage to us, to thosearound us and particularly to the individuals whose wellbeingis our avowed quest.A particular source of concern results from the ‘should andcould’ mismatch.  What we deliver on a personal level to ourpatients (and to the profession as a whole) is limited only bythe extent to which we allow our vocational and ethicalprinciples to guide us.  What we can actually offer our patientsin terms of treatment is often dictated by those who, at differentlevels, are responsible for financing and administering thehealth service of the country.  It is the extent of the discrepancywhich exists between these two aspects that dictates the levelof comfort or otherwise that we feel in our daily practice.We can start by feeling encouraged with the basic qualitieswithout which any medical service would be severelydisadvantaged.  We can be proud of the dedication,professionalism, capabilities and sense of purpose of themedical, paramedical and administrative staff who are involvedin the delivery of our health service at every level.  With theseingredients in place it would seem a relatively easy task toactually provide a prime quality service.  This we manage to dowith varying degrees of difficulty and success.  One of the majorobstacles to reach any aspired goal is the apparent inability thatexists in nurturing and maintaining the positive qualities justmentioned.  These characteristics run the risk of being erodedcompletely unless responsibility and accountability are linkedto authority at different levels.Those of us who accept the burden of responsibility andaccountability for the service we deliver have to be given theauthority required to actually deliver it to the standards we aretaught and trained to expect.  The term authority in this contextsimply means that the considerations and opinions of those whoactually deliver a service have to be taken on board and actedupon by those whose duty it is to finance and administer it.  Anabsence of this process will inevitably erode the confidence onehas in the system.  Furthermore, the particular contentment ordiscomfort felt with the level of service finally delivered willdoubtless have a bearing on individuals, their performance andthe determination and pride they inject into their work.Those involved in the actual delivery of health care aretaught and trained not only to provide a level of care that is ofthe highest quality but are also bound to keep up to date withthe ongoing developments in the profession.  Medicine is asubject that is increasingly expanding in leaps and bounds bothin the pharmacological and technical areas and this invariablyhas significant cost implications that cause great problems withdepartments of finance in every country that boasts a nationalhealth service.We depend entirely on a system that is based on a NationalHealth Care system established in the 50’s which boundgovernments of the day to provide ‘health care for all’.  It isimplicit in this tenet that the standard of health care deliveryhas to be based on valid and accepted contemporary practicesin the field of Medicine.  Until the early 70’s our system allowedfor means testing of individuals dictating the level ofcontribution for the delivery of the service which was itselfsubsidised at source.  Those whose earnings were below a certainceiling were exempt from any payment whatsoever. The systemwas then changed to supply a free service to all and this placeda level of responsibility on subsequent governments whichalthough as a principle was proudly proclaimed as one deservingof a crown of laurel, in practice turned out to be nothing shortof a financial mill stone as the years (and the practice ofmedicine) progressed.The crux of the problem lies in the ‘should and could’disparity mentioned earlier.  The profession is taught first todeliver the best and the most up to date service with financialconstraints coming as a resulting consideration.  Departmentsof finance use financial considerations first to dictate the levelof service they consider possible.  Thus the medical professionknows what it ‘should’ be delivering which is sometimesdifferent to what it actually ‘could’ do by a system seeminglyunable or unprepared to share in its priorities.Cost containment and cost cutting are the main tools usedto tailor any service.  While we all understand that excesses haveto be contained and superfluous items abandoned none of usfeel that this should be at the expense of the level of care expectedor given.  In reality, cost containment usually makes it difficultto advance the standards of care and cost cutting does nothingAlbert Fenech MD FRCPDepartment of CardiologySt Luke’s Hospital, Gwardamangia, MaltaEmail: albert.fenech@gov.mt8 Malta Medical Journal    Volume 17   Issue 02   July 2005but diminish them.  It would be refreshing if the medicalprofession would be allowed to work with the Departments ofHealth as well as Finance to agree on areas of cost improvementbut at the same time allowing the standard of medicine to moveforward at a mutually acceptable pace.There are a number of burning issues that have resulted inconsiderable distress to all by remaining unresolved and it isdifficult to understand their chronic and continued apparentdisregard.  It is a policy that is as short sighted as it is dangerousnot to maintain the required staffing levels necessary to sustainour health service.  Not even attempting to replace staff whohave left the service on either a temporary or permanent basisis a recipe for unfair hardship to both staff and patients alike.Allowing essential items of stock to run low or to actually depletegives the health service as a whole an undeservedly badreputation.  Not taking into account the decades-long financialpackage for medical staff is now showing its inevitableconsequence with individuals considering leaving the islandsfor countries with far better conditions and prospects.  The wasteof investment in teaching and training let alone humanresources beggars belief and gives credence, perhaps unfairly,to accusations of short-sightedness. The principle ofacknowledging the assistance individual private health plansgive to an overstretched national service has not as yet been putinto practice let alone encouraged in the same way privateretirement plans have.These are but a few of the number of longstanding problemsthat have been hitherto flagged on countless occasions by thoseof us at the front line of the health service.  The absence so far ofany sensible or tangible response has a profoundly discouragingeffect that undermines so many positive qualities that arepresent in abundance.  Solutions in the delivery of an effectivehealth service have to be found by a convergence of minds andprinciples of all those involved in health care delivery.  The ‘usversus them’ mentality that is often engendered between thosewho deliver and those who administer, at varying levels, doesnothing but make progress extremely difficult if not impossibleto achieve.  It is not beyond the realms of possibility to marrythe practice of good medicine with particular fiscal principlesthat are meant to sustain it.  This goes a long way in allowingfor the continuation and inevitable evolutionary process thatthe health of any nation requires.

Sense and sensibilities

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Sense and sensibilities

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