Tuesday, January 5, 2010

1M Clinics: Additional Comments...

1M Clinics: Additional Comments...

Datuk Dr Teoh Siang Chin:
I am a bit late in replying - been away on leave.

i would like to give some input :

We cannot oppose (Publicly ) the clinics - the public/ patients and media have seen this as a expansion of health care services.

we can only state our concern for the quality of care as you so rightly put it.

However, i understand very well the perceived threat by our members in primary care - they are right in that this should have been done in consultation with MMA.

maybe some of our members would be able to over see and work part time there. (unlikely to get rate of RM 80 per  hour. more like  rm 30 -50 per hour.)

if we can find a hundred private members (two per clinic) willing to do this -

we will benefit the community by providing better professional care.

 MMA can be a partner to 1MC - we be the good guys to announce that our doctors willing to serve - to provide better care. - (negotiate the rate later - in private) .

This will be seen as a good gesture by the community - MMA eager to provide higher quality care.

A correction - it is  RM 10 million for fifty clinics - which is  RM 200k per clinic per year.-

(including rental/ furniture and equipment / consumables/ medicines -  but probably not salaries.)

We have to be quick to seize the intiative -

The launch of the first 1MC is on 7th in kg kerinchi pantai dalam by the PM..

Has MMA been invited?

The meeting with MOH is after the launch -

SO - May i suggest :

Today - a well worded press statement:

1) Seeing the establishment of 1MC as a positive development  to provide better coverage for the urban poor.

2) and YET positioning MMA and our members' concern about quality of care -

3) (Solution) and then volunteering our professional oversight during the period of lack of medical officers - a good private public partnership.

AND thanking the MOH for agreeing to a meeting on friday ..

then DURING the meeting then ask all the difficult questions - re the PHFCSA provisions etc .

Also prepare  a press release for post meeting..friday..

Maj Gen Dato' Dr R Mohanadas:

Thanks so much for initiating this ongoing dialogue.I have read your letter in the NST and the reply too by the DG. We have to be cautious in handling this dialogue on Friday to arrive at a win-win formula..... I did not get to my e mails till yesterday as I had taken a year end break!!
My thoughts are (remember I am not in active clinical practice, and all my 30 years in military service is provision of community healthcare, and now involved in the training of healthcare professionals!!!):
a.   The MMA is still the largest single body to represent the interest of the profession (though our percentage in relation to total numbers keep decreasing). Therefore we are correct in highlighting the concerns of the GPs.......but the perception created is that:
      (1) the income of the GPs will be affected by the 1 Malaysia Clinics.This seems to be foremost in the minds of the public. (we agree but to me, it will be  a very small dent with the 50 clincs for now).
      (2) this has to be balanced with our community role as a medical profession.....I do not remember the exact words in the MMA Consitution, but have the MMAF M&A here. It says 'to look into the problems of the health of this nation, the system of delivery of healthcare to rural and urban areas'.
b. Quote...the Govt is taking a step back by using MAs (now called Asst Medical Officers) is incorrect. Yes, legally so, if without supervision. The Govt can easily overcome this by naming PICs for each clinic from the nearest Govt Facility, and maybe send them out to the 1 Malaysia Clinics for a few hours each day?..........again we lose the battle.............
c. Training of Nurses and MAs have changed, unlike our days!!..........Students now opt for a first degree in Nursing which is a 4 year programme after STPM!..not SPM.....(again crudely as some parents put it at the education fairs...'what only one year less than studying to be a doctor'.).............(disregard the entry qualifications for medicine and content of the medical curriculum!)..........besides MAHSA, there are several IPTAs and IPTS offering degrees in Nursing.........I have heard some paper presentations by these girls and they are good!....................Next is the conversion from diploma to degrees in Nursing, and this 2 year part time programme called top up is fully subscribed in all IPTS that offer........we have graduated probably a 1000 working nurses with these degrees................and a much higher than this figure are currently enrolled with us......................MAs too, easily some 200 of them are on the degree programmes with us (MAHSA).................another interesting development is the Masters in Healthcare, with emphasis in clinical care...................this is conducted by LJMU with MAHSA....this is to produce Nurse Practitioners, and some who are enrolled in this programme are targeting Australia for work after the course...................(I hope I am not seen to be advertsinig for MAHSA!!......but just to say that there is a big shift in Nurse/MA training and education, ).....................therefore we should only lightly hit this issue on Friday..........or atleast indicate that we are fully aware of these developments and yet..........
d. I met a retiree in his 70s who welcomed this 1Malaysia Cilinc and said that it will be easier for me to change my catheter (he had spinal surgery a year ago). Another was a girl, working in the private sector in KL for RM 2000, who shares an apartment in Kg Kerinci...............she thinks no problems with Nurses treating her 2 kids, 'sebab lebih senang dia orang bolih hantar ke hospital kalau sakit teruk'.............again being too vocal against the 1Malaysia Clinics I feel may not get good community support........
e. MMA is concerned that there will be a glut of doctors sooner than expected, though currently a I uderstand in the last declared figures only 55% of the MO appointments in Govt is filled.........these 1 Malaysia Clinics will be welcomed by some of our own new graduates, especially those who still fear far away postings.
f. The 'political' aspect in this issue I feel is only the word "1Malaysia"...........the positive aspect is better access to healthcare for the rakyat....inview of the ever increasing numbers of low income earners in urban areas.......the negative aspect is its effect on the GPs, again where an established GP with good clinical skills and the right dose of doctor-patient relationship should have no worries??
g. Politics again, we all know, and I am sure the Govt also knows the low voter registration from the medical profession and the low voter turnout though once in five years!!.........If we were in Govt we would also be targetting the people who would atleast take the time to vote (disregardig who one votes for).........!!...I know doctors my age who have never voted!!!!
So where is this win-win formula???:
a. My suggestion will be..........we welcome these additional clinics in the interest of the rakyat............it is good their health needs are addressed.........but please give the GPs in that area the first oppurtunity to service these clinics at a payment of RM ....per hour........(MMA's duty to its members).
b. If the GPs do not come forward, then please assure the rakyat are given a higher level of service by posting Govt MOs into these clinics..........(MMA's duty to the rakyat).
c. If the Govt still chooses to expand these clinics, to consult MMA for views on locations.
Finally, I am against any form of action other than dialogue with the authorities.................no peace walk, no static placard demos, no signature campaigns............we should do none of these to mar the nobility of our pofession........remember this year is our 50th Anniversary and you talked about programmes that wll be seen to benefit the community  throughout 2010!! (tough,eh being President, balancing both!!!)....Good Luck
Dr David, I am sure my views may not be in total agreement with many, but as you have always said, we are mature enough to hear differing views!
Wish you well for 2010 and have a successful meeting on Friday.
Dr KC Koh:
I am in concurrence with Datuk Teoh.
My opinion has always been to avoid rash decisions and to stress on the fact that the 1Malaysia clinics are going to be manned by under qualified staff.
And also it's unlikely to be a threat to most GPs as patients who will visit 1Malaysia Clinics are most likely those who in the first place, will not pay to see a private GP.
However, I see a threat here, in that MMA is not being consulted on a host of issues concerning healthcare delivery in our country.
Datuk Dr Sarjeet Singh Siddhu:
We are in a no-win situation here. We are damned if we oppose and we are damned if we don’t. But we had better sit back a little and see where we are really heading.
The letters from the Public, the one from Australia in “The Star” today (likely from a para-medic), the DG’s response, and the like do not augur well for the doctors from the viewpoint of their “rice bowl”.
(I will refer to all paramedics / healthcare providers, both local and foreign as MAs for convenience.)
Some issues that need consideration:
  1. The DG’s statement that the MAs will, inter alia, “change a bladder catheter or dress a minor injury”; that “They are qualified to carry out minor surgical procedures and are allowed to use specific surgical instruments under the Medical Act 1971” is a matter of fact that will sit very easy with the public. Indeed it IS being welcomed by almost every lay citizen.
  2. The public is aware that non-doctors in developed countries undertake such tasks and treatments, and the letter in the Star (from some Aussie) endorses this perception. That the reasons for this “task shifting” in the West may be quite different from what we face locally will remain irrelevant to the Public.
  3. Our argument that providing MAs where abundant doctors are available (urban areas) amounts to a “downgrade” is supportable. But it does not negate the use of MAs in areas where no doctors are available (parts of the Country), and so we are not against such “task shifting” where necessary.
  4. Our argument that we object because we feel patients are being short-changed, that the objection is entirely or mainly on these altruistic grounds, does not ring true entirely. We have to admit that the key cause for the objection is that these 1MCs will cut into GP incomes. This is not to say that such concern is wrong; indeed so many GPs can barely make what new MOs in Govt service now make.
  5. Work out a system that employs GPs (as Govt locums) at rates now payable to Govt doctors. Eventually they are going to have (more than) enough doctors of their own to man/run these clinics
  6. Much is being made, by certain individuals and quarters, about the 1MCs being illegal (ie against the PHSFA) and that we should lodge police reports and/or seek a High Court injunction.  But, as I see it, the PHSFA is not applicable to the Govt hospitals/clinics. So let us forget about the legalities (unless I am wrong in my interpretation).
I do not have the answers to the issues raised above but these need to be considered.
Since we are asked to bring other doctors, besides the MMA reps, we can get the GPs to come (as a show of strength and solidarity) but we must take pains to assure the authorities that this is not a protest demonstration a la street demos.
Take the PPS Committe along as suggested by Mohan.
My Feedback Comments (DQ):
SC, sorry you were away, but I think you cannot seriously think that MMA should support the 1Malaysia clinic as it stands!!??

Pls follow all the postings on this. Join our facebook discussion group to be updated on what has transpired.

There is not only a real risk of further arbitrary actions from the MOH, but also that potential threat of task-shifting which is now mooted in DG's letter to NST after our MMA's response earlier.

You are right, I have in my earlier malaysiakini comment (also in our Berita MMA) stated that each clinic is allocated some RM200,000, but what Dr Mastura mentioned is what is initially allowed i.e. RM30,000 for the set up. The public purse is having some financial shortages.

However, although the opening and launching of the 1M clinic is unstoppable, we should still lodge our strongest protests and opposition which is what most doctors and members feel, but perhaps not by demos and placards.

Your points about quality of care has already been discussed at length in the media (when published) by me as president of the MMA, but I guess you were not accessing any local news, while away. See my blog or the facebook blog for the threads in almost all the exchanges...

But I agree with your points of using this turn of events to perhaps suggest the manning of these clinics by locums from the private sector which is a good alternative, although I think it will not materialise, as the budget for such locums is clearly not been factored in and there is already a health expenditure cut by 4.8%, for 2010. (Working on the basis of locum reimbursement of RM40 to 80 per hour, this would cost RM8.76 million to RM17.52 million ringgit for the locums for 50 clinics, 12hs/day for 365 days a year!)

Remember that we have suggested that they man the clinics with govt MOs, but this was not even entertained, so we can just propose and try, but I am not hopeful.

The exco will meet Wed to help come out with some more concrete proposals. I will of also try to get out some press statements which have a habit of being delayed or even shelved, unfortunately...

The Sun just published some bits of an interview I had with Ms Karen Arukesamy.

The Sun, Tuesday, 05.01.10
Docs circulating SMS about 1Malaysia clinics protest
Karen Arukesamy

PETALING JAYA (Jan 4, 2010): A text message via the short-messaging-service (SMS) is circulating amongst private doctors on a proposed placard protest to be held within the Malaysian Medical Association (MMA) compound, against the government’s 1Malaysia clinics.

The SMS also states that the MMA will lodge an official complaint to Malaysian Medical Council (MMC) against the Health Ministry and a police report against "illegal 1Malaysia clinics for doping the public."

When contacted MMA president Dr David K L Quek told theSun today that he was aware of the circulating SMS.
"I am aware of it. It is not from MMA but from some doctors, who are dissatisfied and unhappy with the setting up of the 1Malaysia Clinics to be manned by health assistants and staff nurses. Nothing will take place unless we agree to it," he said.

"Many of the general practitioners are very unhappy to see that the government is shifting down the tasks. We are not against the poor getting free treatment but there are long term implications to it."

On Dec 16, Health Minister Datuk Seri Liow Tiong Lai had announced that 50 1Malaysia community clinics, which will be launched simultaneously on Thursday, will begin operation this month to provide fast basic health treatment for urban poor residents.

Liow said it will save patients’ waiting time to seek treatment for minor ailments and will help to reduce the outpatient load at the accident and emergency units.

Prime Minister Datuk Seri Najib Abdul Razak had announced an allocation of RM10 million under Budget 2010 for the community clinic programme.

The clinics, which will be opened from 10am to 10pm daily, will be managed by a medical assistant and a nurse and would be at locations easily accessible by the public in residential areas with a population of more than 10,000 people.

However the community clinic programme was not welcomed by MMA and private doctors.

Emphasising that policy shifts should include greater dialogue with doctors as their potential livelihood and practice will be affected, Quek stressed that most of the general practitioners are very upset and angered by this move.

Quek said the government cited other countries as having implemented similar community clinic programmes, but noted that most of the medical assistants and nurses there hold bachelors' degrees and extra diplomas specialising in certain medical fields.

"But here, a lot of them are just SPM holders who attend a three-year-course They may not have enough training in handling certain cases," he said.

Reiterating that MMA is not opposed to the poor getting free and good treatment for health and medical needs, he said: "The poor deserves good treatment and there should not be shifting of tasks, just because they cannot afford it."

"Our concerns are more in principle that we should utilise more doctors and indeed enlist the special expertise of the medical assistants and experienced nurses together but under direct supervision of a doctor in any clinic, but inline with their training," Quek said.

He urged the government to consider the plights doctors who have been trained at huge expense, parents who have spent enormous amounts of money to ensure that their children can become doctors, and who may in the near future have not enough work to do.

"MMA is naturally concerned about these graduates," he said, adding that it does not want things to go to the extent where the doctors are marginalised.

Quek noted that it is projected that by 2015, the country may have as many as 35,000 to 45,000 doctors.

He said MMA has worked very closely and cooperated with the Health Ministry over many issues, and it is "not simply opposing, just out of spite".

"As a president elected to serve the members, I have to answer to their plight and misgivings, although as a specialist I am not at all affected at all by this issue of 1Malaysia clinics," he said.

Quek said MMA hopes to work with the ministry to resolve this unintended crisis of confidence, adding that the Health Ministry has agreed to hold a dialogue with MMA at the ministry on Friday to solve the problem.

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