by Prof. Pierre Mallia
There are a number of EU directives which apply to the rights of EU citizens to receive medical health care when outside their country but within the European Union. This applies mostly to emergency treatment and has also proved of benefit to those who cannot receive a procedure, for example, within their country of origin either due to lack of the service or merely because of undue prolonged waiting. Yet the EU was set up as an economic zone and therefore includes the facilitation of transfer of workers between EU states.
When it comes to transfer of workers, especially those travelling with their family, primary health becomes all the more important. EU states differ considerably between themselves on the type of service they offer. Some are mostly state-based; others insurance based. Certainly if one is to travel to another country, say Holland, with one’s family, it is a concern, if not a headache, to consider what kind of health services are offered for day-to-day ailments which necessitate the calling of a doctor. In Malta one may be used to call one’s GP at home and get prompt service. But this is a private service which is not, by right, entitled to other EU citizens. They would have to pay for it. Considering the small fee local family doctors charge, it is worth the while of any EU citizen travelling here to call a family doctor at one’s home. Even if one had to go to a health centre, the service would be given on the same day. Not so in the UK, for example, where locals would have to wait up to a couple of weeks for an appointment and only emergencies are treated on the same day – and probably not at home.
Certainly, finding out about a health system is the last thing on many people’s minds when travelling to another country. If one is intending to travel for a few months or a few years, one has already many headaches like finding a house or apartment, schools for the children etc. If the EU is to become what it was intended to become – a zone in which all EU citizens can transfer for work opportunities, and not remain merely an opportunity zone for the younger generation only, then one has to cater for the transfer of families.
This is certainly not new. In research, for example, there are various schemes which provide for the transfer of researchers from one country to another. One fund, the Marie Curie, was set up to allow the transfer of those researchers who had less opportunity in their area of research in their locality, to transfer to more renowned centres. These funds catered for the transfer of one’s family and even, in some cases, schools.
But such opportunities may exist only within certain schemes. Certainly to ‘remove barriers’, one must make it as easy as, say, Americans transferring with their children and spouses from one state to another. One big obstacle which we find in Europe (but which Americans do not find) is primary health care – or in more lay terms, the family doctor (many may still refer to him/her as GP).
Imagine again travelling to Holland and once there, one’s daughter falls ill with gastritis. It would certainly be less of a headache if the system there was the same as in Malta. One would be given several telephone numbers and one simply calls the doctor. It may not be easy to find a system that works as efficiently and effectively as in Malta. I say this not because I am a local family doctor as well, but because it is the reality. For a mere five or seven euros one sees a GP in the office, perhaps after an hour’s wait. If one were to go to a GP in another country one certainly would spend 10 to 15 times as much. One appreciates what one has (or has left behind) when one does not have it any longer. Yet some form of harmonisation would be very convenient.
This agenda is being taken up locally by the Bioethics Research Programme of the Medical School at Mater Dei. Together with the Faculty of Medicine at the University of Maastricht, we hope to propose a project of study of this cross border primary care problem. There are several areas of concern which are all related to primary care. In the first instance what one considers emergencies are not always emergencies. A mother once told me (when we had introduced the system that after 5pm, health centres had to see only emergencies), that for her, a fever, or a mere sore throat of a two-year old was an emergency, especially when the media feeds the public signs to look out for and when they hear of other people’s experiences. Did not that baby with a sore throat end up in hospital with croup? Did not that rash turn out to be meningitis? Did not that fever reflect an appendix? Mothers can be very anxious. It is the family doctor’s job to reflect and decide who should be referred to hospital and who should be treated at home. It is also his or her job then to reassure the parents and give them some form of safety net if things get worse.
Other jobs of family doctors are preventive medicine, taking care of chronic conditions and giving other forms of social advice. Someone travelling to another State would be concerned about his or her hypertension or diabetes. Where are they to go for their follow-up visits; where do they get their treatment from; who are they to call in case of worry or an emergency? If one has a son who suffers from asthma or an allergy, one cannot rely solely on self-management. Although it is easy to call one’s doctor back home, when one is away for a long period of time, one needs a point of contact. Someone cannot simply turn up at an emergency every time something goes wrong. Conversely, while people get used to the primary care system as time passes, it would be much easier if systems were approximately the same.
Now there are various theories of EU integration. They vary from mere economic with no need for making systems uniform to theories, which allow for more coherent and integrated systems. Would it not be easy if my family doctor at home would simply ask me where I am going and through a computerised system find out the local family doctors and transfer my records electronically? That would be one headache, which can save lives, off one’s list. One can then dedicate more time to settle down at work and finding schools and where to live.
Whatever theory of EU integration one uses, the main concern is, at the end of the day, the facilitation of transfer of workers between states. Many directives have been written in this spirit. This includes, for example, the EU Directive on Data Protection which is not there to protect this fundamental right and freedom of the individual (privacy) but to facilitate the transfer of information (data) between EU States. It assumes that fundamental rights are protected within the framework of local laws. The same can be true when thinking of health. A directive for countries would indicate to member states what they should be after. This would not only, incidentally, bring more harmonisation for those who are travelling, but, as with other directives, would ensure that all EU citizens, would, at the end of the day, be receiving appropriate health care.
This is no easy matter. One would need to study the systems in all other States and take common denominators and see what the needs are to harmonise systems. Certainly the WHO stipulates that good primary health care systems are the key to an overall good health care system. We often go along with the wrong impression that a good hospital equates with a good health care system. This is wrong. A good hospital is just that, a good hospital. When the system is wrong, that good hospital is taxed to an extent that disallows it from functioning effectively and efficiently. We need not go far to understand this! The increased waiting time in our local hospital was, at least partially, identified with a weakness in our primary health care. Inappropriate referrals because local GPs do not have adequate facilities, or indeed self-referral by patients themselves, has led the department of health to call for GPs to work at the emergency department, to see patients who did not actually need to turn up at casualty.
This happens in many countries where general practice is not yet developed into an efficient system. Of course such a system would need the registration of patients with a family doctor; doctors need to be more organised to cover each other when they are off duty or on leave, or indeed sick; whether group practice or solo practice, one has to see that there is harmony within the system, and last but not least one has to ensure that all doctors working in the community are on the Specialist register and are equipped to deal with semi-emergencies, which would in turn relieve hospitals. Registration alone is not the answer. Registration brings with it organisation, without which it would simply not work.
While we are re-thinking our primary health care system, it would be wise to watch out for these developments. Certainly there are many other EU-funded projects dealing with this important area. We need to be able not only to handle EU citizens who come here; but to ensure that local people who seek opportunity within the EU continue to get optimal care and a family service. Our system is in need of a re-vamp. The tensions which have arisen lately are simply the result of an accumulation of problems which have been tackled poorly. It is also true that were it not for private GPs, no one in Malta would be able to answer the question, ‘who is your doctor?’, or to react to ‘take this to your doctor’. Health centres are made of excellent doctors working in a poor system, created in a communist period (polyclinics were introduced in Russia) which even they have largely purged.
Perhaps what is also in need of a re-vamp is the National Development Day which the Malta College of Family Doctors started when I was president, to bring all stakeholders together – we had doctors from all sectors, ministers, and others – to discuss where we want to go over the next 10 to 20 years. It started by people being weary that their turf needs protection. But change will bring about benefits besides the sacrifices. Experience in other areas has shown that the benefits always outweigh the sacrifices. In re-thinking our primary system, however we may wish to look at the future of the EU as well and keep ourselves posted on this issue.
Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta.
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