4.2 Human resources
4.2.1 Planning and registration of human resources
The majority of future health care workers are trained at the University of Malta Faculty of Health Sciences and Faculty of Medicine and Surgery. There are fixed numbers of students for dentistry and most allied health degree courses. The degree courses for doctor of medicine and surgery, pharmacy and nursing do not operate a fixed number clause to limit the number of places available. There are plans to open a medical school in Gozo in partnership with Barts and The London School of Medicine and Dentistry and a second nursing school. The Malta College for Science, Arts and Technology (MCAST) plays an important role in training care workers and clinical aides to the professions.
Since Malta’s EU membership, there have been several initiatives to introduce specialized postgraduate training programmes for doctors. This trend is now also being taken up in the allied health professions and nursing.
There are a number of regulatory councils responsible for the registration of qualified practitioners. These include the Medical Council (doctors, dentists), the Pharmacy Council, the Council for Nurses and Midwives, and the Council for Professions Complementary to Medicine. These are all regulated under the Health Care Professions Act. In addition, with regard to doctors, there is also a Specialist Accreditation Committee which certifies doctors who have completed their specialist training within different respective fields. As an EU Member State, Malta is now obliged to implement Continuous Professional Development as per Directive 2013/55/EU but as yet there are no revalidation mechanisms in place.
4.2.2 Trends in the health workforce
The health sector is one of the largest employers. In 2015, 30.3% of total Ministry for Health recurrent expenditure was allocated for salaries. Government health-sector employees are civil servants. In addition to health professionals, various categories of support staff, ranging from auxiliary workers to clerical workers to engineers, make up the health care workforce. (See Box4.2 for the geographical distribution of health workers.) Safeguarding the status of workers in the public health system is one of the key issues that has been discussed in the proposed public–private partnership model between the Government and the unions representing health care workers.
The number of physicians per 100 000 population (inclusive of specialist trainees) has been rising steadily in recent years and in 2013 reached the EU average (Fig4.2). This is the result of a combination of factors. The number of medical students has more than doubled annually over the past 10 years. The development of the UK Malta Foundation Programme has been instrumental in retaining medical graduates in Malta. Also, the setting-up of formal specialization training programmes held primarily in Malta with fixed periods of training overseas have contributed to counteract the medical brain drain which was experienced immediately upon accession to the EU.
In 2015 there were 391 physicians per 100 000 population, 65% of whom were working in hospitals. The number of physicians in Malta has now exceeded the EU average. The number of GPs has been increasing steadily and has now reached 83 per 100 000 population, again surpassing the EU average. Malta has a very small number of full-time academic physicians but a large proportion of medical specialists are also engaged in teaching and research activities.
Nurses and midwives
From 2009 onwards, data refer to nurses employed in state and private institutions. The number of nurses has increased steadily in recent years from 709 per 100 000 population in 2012 to 867 per 100 000 in 2015 (Fig4.3). Malta has a relatively high number of midwives, with 47 per 100 000 population in 2015.
In 2015 Malta still had a low number of dentists per population at 49 per 100 000 (Fig4.4). This is well below the EU average and could be explained by the fixed number clause capping the number of dental students accepted by the University of Malta at eight per year (Kravitz et al., 2015).
In 2009 the Pharmacy Council changed its methodology to count the number of practising pharmacists rather than all persons registered as pharmacists. The change in methodology led to significant fluctuations in this figure, making cross-country comparison difficult (Fig4.5). The number of pharmacists in 2015 stood at 133 per 100 000 population, up from 115.34 in 2014. This is the highest amongst the comparator countries and well above the EU average.
Public health professionals
In Malta the specialty of public health medicine is listed as one of the specializations on the medical specialist register. Medical doctors undergo four years of training in public health after successfully completing a two-year period of foundation training to obtain their full medical registration (Ministry for Health, 2016d). The University of Malta offers an MSc in Public Health which is also open to nonmedical graduates. There are 42 public health physicians and 10 medical specialist trainees in public health medicine (Ministry for Health, 2016d). Medical specialists in public health are assisted by various other professionals, including environmental health officers, nurses, nutritionists, allied health professionals and statisticians since public health practice is considered to be interdisciplinary in nature.
Professionals allied to medicine
There are wide varieties of other types of health care professionals. The most common are medical laboratory scientists, physiotherapists and radiographers.
In September 2010 a directorate was set up within the Ministry for Health to coordinate allied health care professions within the diverse network of public providers, to bridge any gaps and ensure that providers work together for the benefit of patients and their carers. Through European Funding and as a result of the new SAMOC, there was a concerted effort to improve capacity-building within the area of medical physics, with a number of Maltese students going abroad to undertake undergraduate degrees in this field. Furthermore, the undergraduate degree for radiography introduced increased elements of radiotherapy within their curriculum to adapt for the increased demand.
The Government relies on foreign consultants for some types of service, including both orthotics and prosthetics. Likewise, the Government has an agreement with the Chinese Government whereby an acupuncturist is available daily at MDH, with one doctor in attendance, and once weekly in Gozo. Moreover, the Chinese Government supports the purchase of equipment and medicines for these facilities. Traditional Chinese medicine is also available in the private sector.
The positions of Director General and Director within the Ministry for Health are filled through calls for headship positions issued by the Office of the Prime Minister. Within hospitals, nonclinical managers are usually appointed through the Foundation for Medical Services, whilst Clinical Chairs, Nursing Managers and Managers in the allied health professions are selected via competitive selection processes managed through the Public Service Commission1 and in line with criteria set out in the respective collective agreements.
Social workers and care workers
Social workers have their own accreditation system and are given a warrant once they complete the required amount of work experience. The Social Work Profession Board is regulated by the Social Work Profession Act and the board members are appointed by the Minister for the Family and Social Solidarity. The board processes applications for the Social Work Warrant. The majority of care workers are employed by the private sector and a number of courses are offered by different institutions to provide for their educational and training needs.
4.2.3 Professional mobility of health workers
Following EU accession, Malta experienced a severe net outflow of newly graduated doctors, mainly to the United Kingdom, where Maltese doctors traditionally carry out their specialization training.
Other paramedical professions have been experiencing this brain drain to a much lesser extent. The outflow of doctors was addressed in the recent past through the mutual recognition of medical training in Malta between the United Kingdom General Medical Council and the Maltese Medical Council, the establishment of formal specialization programmes in Malta coordinated by a postgraduate training facility, and through renegotiation of the health care professional collective agreement which has improved the remuneration package.
In the nursing profession 9% of the workforce is foreign, with 28 unique nationalities. During 2014 there were a number of recruitment drives and official bilateral agreements to obtain nurses from different countries, such as Spain and Cyprus.
4.2.4 Training of health personnel
Training of health care professionals within Malta takes place at the University of Malta. Doctors, pharmacists and dentists are trained at the Medical School within the Faculty of Medicine and Surgery, and the Faculty of Dentistry; the Medical School is over 400 years old. The number of dentists commencing training is still limited by means of a numerus clausus system due to the small number of training places. Removal of the University of Malta’s numerus clausus has helped to maintain an adequate supply of medical graduates. Since the intake of medical and pharmacy students has grown considerably in recent years, some concerns are being voiced about a possible reduction in the quality of clinical teaching (Caruana, 2015). This is an important issue in view of the setting-up of overseas medical and nursing schools. It is important to ensure that while a steady flow of graduates is maintained, the quality of teaching is not compromised. After basic training doctors are required to carry out two years of practical training, working under supervision, before being registered as fully qualified practitioners.
Training for nurses and paramedical professions takes place within the Faculty of Health Sciences; since 1988 there has been a transition from training nurses and paramedical staff at the Department of Health to the University of Malta. The Faculty of Health Sciences now mainly offers degree courses, although some diploma courses are still running, such as for nursing. Some Master’s courses are offered and in-service training courses are also organized. All training conducted has been certified as being fully compliant with EU requirements.
Accession to the EU has made it easier for doctors to train and work abroad. The Ministry for Health has obtained bilateral accreditation of the local medical training programme with the United Kingdom General Medical Council. That, together with the creation of formal training programmes leading to specialist accreditation, has significantly restricted the outflow of Maltese graduates.
The 2004 Health-Care Professions Act set up a specialist accreditation body and specialist registers for doctors, in line with EU requirements. The process of accrediting specialists already practising as well as laying down requirements for entry into the specialist registers has been completed.
To date there is no specialist accreditation structure for the nursing profession. There have been concerted efforts to empower nurses to further their training in different areas, e.g. diabetes, infection control, tissue viability, pain management and radiotherapy.
The official body for setting education standards within Malta is the National Commission for Further and Higher Education (NCFHE).
4.2.5 Physicians’ career paths
Graduating medical doctors are expected to join a two-year foundation training programme, at the end of which they are encouraged to take up specialist training. Recruitment into a specialist training programme is subject to a competitive call for basic specialist trainees (BSTs), which is regulated by the general public service recruitment framework. The portfolio that doctors are required to keep during their foundation years (which includes feedback from supervising consultants) is considered as part of candidates’ assessment. Most specialties have their own structured training programmes, lasting between four and five years in total, during which candidates are required to obtain relevant qualifications either locally or abroad. After obtaining such qualifications, BSTs are eligible to apply for higher specialist trainee posts. Upon completion of the respective training programme, candidates are awarded their specialist accreditation and automatically provided with resident specialist status. Upon completion of two years at resident specialist level, specialists may apply for consultant or designate consultant (shadowing a retiring consultant) posts. This system is slightly different for GP posts, but still requires the successful completion of a three-year formal specialist training programme with an exit exam to follow a career path in family medicine.
Posts are always created by the Ministry for Health following approval by the Ministry for Finance as part of an annual capacity-building exercise. Post descriptions are endorsed by the Public Service Commission to ensure that they are in line with public service regulations and needs and then advertised publicly via the Government’s online recruitment portal and the Government Gazette. Clinical posts may be created by the Ministry for Health. Promotion of staff is organized at national level and at this point in time physicians are not moving around as much as other health care professions.
4.2.6 Other health workers’ career paths
In 1996 the Directorate of Nursing Services was set up, symbolizing the growing importance of the field. The Health-Care Professions Act has given nurses a greater sense of autonomy and self-regulation. Specialist nursing opportunities have been created to allow nurses to take up more specialist tasks within their clinical stream.
Other allied health care professions and pharmacists work within the civil service or the private sector, similar to doctors and nurses. Amongst allied health care professions, promotions are also organized at the national level.
For all public sector health care workers, promotions are governed through criteria established in the respective collective agreements and implemented by the Public Service Commission.