Friday, December 18, 2009

MMA’s Grave Concern about 1Malaysia Clinics being manned by Medical Assistants

MMA’s Grave Concern about 1Malaysia Clinics being manned by Medical Assistants/Nurses

When Prime Minister Najib Razak announced in the Budget 2010, the setting up of 50 1Malaysia clinics in urban areas, the MMA was dumbfounded and perplexed.

That these clinics be set up at all, is perhaps a good exercise in public relations for our Prime Minister, who must have genuinely felt the need to offer some much needed goodwill to the urban folks, especially the poor and the marginalised.

However, what is more disturbing is the plan to have these clinics run by medical assistants and/or nurses, which in effect places the standard of these clinics at the level of third world countries, where there is a real scarcity of fully-registered physicians. It is certainly a major step backwards for a progressive nation such as Malaysia, which aspires to be fully developed by 2020, just 10 years away.

The Malaysian Medical Association (MMA) is gravely concerned that such a major shift in policy with regards public sector healthcare should be so implemented without sufficient input and discourse with stakeholders, such as the medical practitioners and perhaps even with officials of the Ministry of Health. It has been suggested that some health officials were also taken aback by this announcement, but they have been made to implement this as a directive, come January 2010. (I stand to be corrected on this fact.) It appears that this plan was brought about by fiat, rather than by persuasive rationale or long-term planning.

Firstly, let us reassure the public that the MMA is not simply protecting its turf. Of course, we are keenly interested in the welfare and wellbeing of medical practitioners, but we are also always concerned about our patients, i.e. the rakyat out there, who are our reason to exist, our raison d’être.

We welcome the government’s concern about our rakyat’s health needs. We also recognize that for many urban poor, their only recourse to health care is that offered by the overcrowded and understaffed MOH outpatient clinics. That there have been much queuing and long waiting times is notorious and wasteful in terms of productivity. Certainly we should do better.

We also know that new health ministry directives have been employed to try to shorten waiting times to less than 30 minutes; this has been included as part of the KPI/KRA so proudly announced by the government. Perhaps because of this huge problem, the need to lessen the burden of fixed outpatient clinics and the logistics of manpower distribution has prompted this new approach.

But we also urge the government to recognize that throughout the country, in urban areas, there are already in place many GP clinics, some only a few doors away from each other in almost every urban block of shop-houses or complexes.

There is a severe glut of GPs in urban areas, where in the Klang Valley, Penang, Johor Bahru, Melaka, Ipoh and other major towns. In all these townships and cities, the ratio of doctor to population is around 1 in 400, more than the WHO recommendation of 1 in 600.

While some GPs have been very successful, the great majority is simply ekeing out a meagre and mediocre living, many GPs are seeing less than 20 patients per day and so are under-utilised. This is grossly unproductive and wasteful when seen in the context of the long arduous training and huge expense required for producing any one doctor, whether locally or abroad.

Our problem is learning how to manage the distribution of the doctor-patient function better and more efficiently. It is with this in mind that for several years now, the MMA and the Ministry of Health have been seeking a better public-private partnership in shaping a better health care system for the country.

Unfortunately because of the differential system of fee and/or payment mechanisms, this is proving rather tricky to bring about a cohesive transferable system. Thus, there has even been growing talks about integrating the public-private sector for primary care medical services. This will hopefully seamlessly integrate the use of almost all GPs into a primary care network where the public can register and seek treatment at either public or GP clinics, interchangeably or by choice, with a common reimbursement mechanism. This will undoubtedly be the way forward.

Of course quite a few discrepancies need to be addressed, e.g. differing expectations, possibly standards of every aspect of care, variable amenities available, level of support staff, etc. But these can be worked out, and we are establishing common areas of standardisation, which will then ensure that the public can be assured of and experience as high a standard of health care as possible.

So, in this context, the hurried establishment of the new 1Malaysia Clinics appear irrational and un-called for. If the government feels genuinely that these have to be carried out regardless of the medical profession protestations, then the minimum that it should do, is to ensure that these clinics are duly manned by registered medical doctors, fully in charge of all aspects of the clinics. This standard of medical care should not be compromised.

Why is this such a prerogative? Because in this day and age, it is quite unbecoming to offer a lesser level of care to those citizens just because they cannot afford to pay to see a doctor. Employing medical assistants and nurses to do a doctor’s job is called task-shifting, which is employed mainly in third world countries where there is severe shortage of doctors. To do so in this country would be a major step backwards and in our MMA’s view, shameful and unnecessary.

Do we have enough doctors? Of course we do. It is just the mal-distribution and poor logistics, which need to be addressed. Recently, more than 2,500 new doctors joined the public service as house officers. It is understood that many of these are under-deployed in the various departments of the government hospitals.

Due to the mushrooming of so many medical schools (23 as of this year) in the country, and medical graduates returning from abroad, we will continue to have some 2,000 to 3,000 new doctors returning to our shores annually!

We can certainly tap into this growing number of doctors to help make our public service clinics more efficient. At the very least the public will be better served by some recognized registered medical doctor, although they may just have probationary medical licence—the fact remains that they have had sufficient training and learning. Medical officers, registrars and specialist, (who can also be deployed to enrich the public sector healthcare service, if need be), can supervise these younger doctors.

Why is the MMA so concerned about clinics being manned by medical assistants or other unregistered medical practitioner? Because under the Medical Act, this is illegal.

Because as of now and in the past, doctors who employ such unregistered persons have been charged and penalized for unprofessional conduct, with some severely sanctioned, even suspended or deregistered!

Because medical assistants cannot prescribe any more than some very simple medicines, cannot sign any medical leave chits or write any report, and would become subject to medico-legal challenges, with no precedents.

Because we are concerned that ‘bogus doctors’ should not be allowed to harm our rakyat! In the past there have been some bogus personnel who have continued to defraud many patients because many of them do not know the limits of their level of competence and training—who feel that they are not bound by any laws.

There should not be one law for some and another for others, even if approved by the government or the MOH.

Two wrongs do not make a right.

The MMA believes that setting up 1Malaysia Clinics in urban locales is wasteful, redundant and shortchanging the rakyat. Utilising the already many GP clinics would be the better way forward. 

Furthermore, manning these clinics by other than registered medical doctors is also wrong and undermines the health care service, which leads to a possibly poorer standard of care, which can lead to many uncharted medico-legal problems.

We urge a rethink about this project, and for the MOH to seriously look into the implications of this poorly advised move.

The MMA will strive to work together earnestly with the MOH to help raise the level of healthcare for Malaysians, but not by compromising on the standard of care, or of shortchanging the uninformed rakyat.

Dr David KL Quek, President MMA

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