1. COST EFFECTIVE SPECIALISED HOSPITAL CARE IN AN ISLAND COMMUNITY A case study on the Maltese Islands Bad Hofgastein, Austria 28th September 2002 Dr John M. CACHIA

2. MALTA BASIC FACTS Centre of the Mediterranean Sea 391,415 inhabitants on 7 islands with an area of 316 km 2 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

3. IMPORTANT TRADITION IN MEDICINE AND HEALTH CARE  Knights Hospitallers of the Order of St. John  Nurse of the Mediterranean in Crimean War  Medical care services in WW1 and WW2  Medical School which more than 300 years old  Famous Maltese doctors in Austria, UK, Italy, N. America, and Australia  Basic medical, nursing and paramedical training available at the University of Malta  All specialists trained in UK centres of excellence  Doctors highly influential in Maltese society

4. BENEFITS TO POPULATION  Politicians compete to offer best services  Awareness of limitations imposed by lack of financial resources  Best use of human resources  High level of confidence in health care services as an institution  87% of Maltese are very satisfied or satisfied with public health services  High cost technology and specialised services became available locally  Wider spectrum of services not normally offered to a small catchment population of 390,000

5. 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

6. BALANCE EFFECTIVE CARE QUALITY CARE

7. BALANCE DEVELOP §capital investment §training §recurrent expenditure §availability of supplies TRANSFER §air transport §sick patient §stringent protocol §limited family support §subsistence/accomodat ion

8. BILATERAL HEATH CARE AGREEMENT BETWEEN MALTA AND UK An example of how mutually beneficial is cross-border co- operation between countries

9. Number of patients treated in UK 1990 - 2001

10. COST OF CARE IN THE UK 1990-2001 in MALTESE LIRI(LM1=2.4euro)

11. EFFECTS OF RESTRICTIVE POLICY §No service to complex cases §Enormous waiting lists §Deaths on the waiting list §Over-medication instead of definitive care §Under-provision of care §Inequality §Pressure on politician and service provider

12. 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

13. CARDIAC SURGERY §From 150 operations per annum(1995) to 300 operations per annum(2001) §Waiting list reduced from 18 months to 6 weeks §No distinction on the basis of severity §Severe and urgent receive precedence §Mortality less than 1.5% of operations §8 cardiac transplants from 1996 of whom 6 are alive to date

14. MRI EXAMINATIONS 1997-2001

15. 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

16. THE PRICE OF…. §QUALITY §TREATMENT AND CARE §EQUITY §EFFECTIVENESS §AFFORDABILITY

17. CHALLENGES §Evolving epidemiology of disease §Increasing levels of care requirements §Building the necessary skills and expertise §Introducing sustainable new services

18. CASES CURRENTLY REFERRED ABROAD FOR TREATMENT §Bone marrow transplant §Liver transplant §Complex major spinal surgery §Paediatric Cardiac Surgery §Paediatric endocrinology, neurology, gastroenterology §maxillo-facial surgery §Cochlear implant §Siamese Twins!!!

19. DILEMMA…. §High recurrent and investment cost §Low patient volume §Deskilling of appointed staff SOLUTION…. §Despite logistic constraints referral abroad may be the ONLY option

20. OUR ROLE §Constant vigilance §Updated on technology developments §Share experiences §Increase awareness and resolve §address inherent under-provision caused by insularity §admit that some superspecialised services will never be affordable to develop locally

21. HEALTH PROFESSIONALS and POLITICIANS have to... §come together §understand each other §create the right balance between costs and accessibility …to be of maximum benefit to our citizens who pay us to serve them.

22. THANK YOU FOR THE SPLENDID OPPORTUNITY TO ADDRESS THIS FORUM