Saturday, January 9, 2010

Dialogue with Health Minister: MMA’s Concerns & Reservations regarding the 1Malaysia Clinics

MMA’s Concerns & Reservations regarding the 1Malaysia Clinics

YB Dato’ Sri Liow Tiong Lai, Minister of Health,
Thank you very much for agreeing to have a timely dialogue with doctors and the MMA. I also wish to thank Mr Lim Eng Leong for facilitating this dialogue, which many of our MMA members have called for.
As is now quite well-known to you YB Dato’ Sri, there has been a lot of confusion, anger and fear among many private sector doctors, especially GPs (General Practitioners) throughout the nation when the issue of 1Malaysia Clinic was first broached by the Prime Minister during his Budget 2010 speech in October 2009.

MMA Supports Universal Healthcare for All, especially ready and affordable access for the poor

At the very outset, let me as President of the MMA, reassure the public, the government and the MOH that the MMA has never opposed whatever measures which may bring better access of healthcare to the rakyat, especially the poor and the marginalized, whether in the urban or rural locations.
We fully support every effort to ensure that the poorest among us, as of every citizen of Malaysia, must have easy, affordable and high quality healthcare, as a human right for all.
We fully appreciate that for many decades now, many world authorities, have praised Malaysia’s primary healthcare structure as being among the best among developing countries, the world over. We are proud that nearly every citizen of Malaysia has relatively easy access to a healthcare facility under a radius of less than 5 km.
Therefore, we recognize that this new endeavour by the government to provide 50 re-branded klinik kesihatan as easy-to-access “1Malaysia clinics” to the urban poor, is laudable and is in line with its caring concept.
However, while the MMA supports better, affordable and more accessible healthcare facilities to the public, the manner in which this has been announced, where they are to be sited, as well as the fact that these clinics were to be manned by medical assistants and nurses, took many doctors by surprise.

1Malaysia Clinics Manned by Non-doctors Cause Concern of Quality, Safety for Patients

Initially, my personal opinion is that just 50 clinics around the country would have very little impact on any doctor’s rice-bowl, although the MMA has reservations that opening these in urban areas appear redundant, because we already have so many GP clinics in almost every town in the country.  Datuk Dr Mah Hang Soon of Perak while visiting the soft opening of these clinics, alluded to the fact that there were already some 319 GPs in the four towns where these 1Malaysia clinics have been sited!
What we did not realize is that, many GPs are much angered by this move, which at first glance appear small and inconsequential to some of us. There has been much anxiety and confusion among many GPs from Johor Bahru to Penang, Kota Bharu, Kota Kinabalu and Kuching.

Many Doctors Confused and Angered

I have received literally, no less than hundreds of angry and condemning sms’s and emails demanding that the MMA address this issue, which they felt has been set up to unfairly impact on their services once again. Such was the general impression that they are once again bearing the brunt of perceived one-sided governmental action, following so closely on the heels of the Private Healthcare Facilities and Services Act and Regulations.
The major peeve/concern is the manning of these clinics by non-medically registered personnel, i.e. medical assistants and nurses rather than doctors. This approach appears to many GPs and doctors as taking many steps backward, despite reassurances that there will be oversight and supervision by some doctors from afar.
We thank YAB Prime Minister for trying to reassure us that our doctors will not be impacted, and that these clinics are simply basic ones to cater for monitoring diabetes, hypertension and some simple ailments. YAB PM left the question of expansion of these clinics opened, depending on the success of its popularity… Hence, our concerns remain.

No Real Doctor Shortage, Better Deployment the Answer

MMA believes there is no real shortage of medical doctors. The MMA feels strongly that doctors should be deployed to man these clinics. We understand the logistical problems, which have arisen time and again due to doctor reluctance to be relocated to more rural or remote situations.
Proper and fair deployment with guaranteed career paths for further training or preferred posting after such rostered ‘hardship’ postings will allow greater participation by ambitious younger doctors. Also if these 1Malaysia clinics are now to be part of the expanded public healthcare system, then the MMA believes that even more public sector doctors would be willing to be deployed in rotation or as part of a training initiative for an enhanced family practice/general practice vocation. Even rural or suburban ‘klinik kesihatan’s can be upgraded to doctor-manned clinics which would enhance the overall standard and quality of care for everyone, urban and rural.

Question of Legal Implications of Clinics to be run by Non-Doctors

Almost every one doctor who had complained, believes that this is wrong in law. Our Medical Act dictates that any health/medical clinic should be run by registered doctors only, yet while this is so for the private medical practitioners, there appears to be another law for government-backed facilities where this requirement can be waived!
That there appears to be one law for private doctors and another for the government or MOH has provoked a sense of injustice and deep anger, especially because quite a number of doctors who had fallen foul of this law had been severely punished recently. Some have openly asked why they cannot also employ MAs in their clinics, to look after simple basic health issues too, while each doctor can oversee a few clinics without being physically present!
Of course, the MMA does not and will not condone or encourage any doctor to break the law. There lies our dilemma of such a perceived differential application of the rule of law, which is increasingly questioned by more and more of our more vocal citizens.
If all these 1Malaysia clinics can be manned by doctors, even house or medical officers (registered medical practitioners) then this degree of unhappiness would be much dissipated. The MMA urges an overall upgrading of these clinics to that manned by at least a registered doctor. We believe this will help defuse the situation.

Safety & Quality of Care Concerns are real, likely to be better with Doctors

With such a move, there will not only be improving access to the poor but also ensuring safety, higher quality of care, possibly fewer errors, lessen medico-legal mishaps, despite the payment of only RM1! Of course, we can harness the special capabilities of the MAs and nurses to offer quicker access, but one that is supervised by a doctor. With such a move, the question of legality, more appropriate therapies, timely referral and even medical chits can be resolved.
A recent report by a group of doctors in Penang (Dr Jayabalan T and others, The Star, 07 January 2010, pg N45) stated that “A study in 2009 revealed that medical assistants at government health clinics and government hospitals were found to be responsible for many medication errors. Of the 1,612 prescriptions generated by medical assistants in a single week, 1169 errors were noted and some were critical errors, involving the use of at least one medication categorised as Group B medicine, which only medical officers are authorised to prescribe.”
They concluded that “It must be noted that medical assistants are trained to assist medical officers and not to provide treatment in the same manner as medical officers.” Therefore, safety issues must always be considered. This is not to say that doctors cannot make mistakes, but with far more comprehensive training and education, these errors are expected to be fewer. Medical defence insurance, when taken up by doctors, also helps to ensure greater patient protection.

MMA shares World Medical Association (WMA) Concerns about Uncontrolled Task-Shifting

For many of us in the MMA, the delegation of duties in the 1Malaysia clinics to non-doctors despite its noble intentions of trying to reach out to more of the urban poor, is a form of task-shifting from the medical doctor, which is much feared and roundly cautioned by medical professionals around the world.
While some poorer nations with very short supply of doctors have resorted to task-shifting some of health care to nurse practitioners or health assistants (even encouraged by WHO), this is not the usual exercise for countries aspiring toward a higher standard of care. This contrasts starkly with our vaunted new approach to encourage greater Medical Tourism initiatives, and could lead to questions of uneven healthcare standards, and possibly safety issues. This could unfavourably impact our efforts to promote health tourism from safety conscious foreigners.
It is true that in Australia, UK, USA and some northern European countries, some of these paramedical practitioners have been tasked to look after screening and continued care of some chronic ailments such as diabetic or hypertension control, these are very closely controlled with very clear lines of responsibilities. There are also very different career paths for these health professionals who are usually degree holders with higher educational capacity and they also undergo further clinical practice diploma training.
Importantly, these do not replace the need for doctors, they assist them to help free up more time for more consultative, diagnostic or more special therapeutic roles. This exercise should never be an exercise for economic or other purposes. Safety and Quality of healthcare must always be our prime concern. I enclose here, the two recently passed resolutions and statements by the WMA for your perusal.

Utilise our Extensive GP Network

Our GP clinic network is extensive in the urban setting. All towns small and big have perhaps too many GP clinics. In major cities these are now even excessive and oversupplied. Many clinics are having concerns of viability and under-utilisation. Perhaps, some of these are not sufficiently popular because of poor preparation or other reasons, but most can be improved upon with proper distribution or dispersal of patients.
Therefore, many GPs have asked why they have not been roped in to help out in these clinics for the poor, if only the MOH or government can help reimburse these clinics to help out. We understand the differences in expectations, amenities and perhaps problems with reimbursement protocols, but these can be worked out for the benefit of all. Our GPs stand ready to be incorporated into a partnership, even an integrated system for better primary care for all our citizens.
The MMA is leading a primary healthcare workgroup to coordinate measures to raise the standards and quality of patient care among all our GPs and/or family physicians. This will enhance the quality of care even higher for our citizens. We are also working with the MOH to see how we partner or integrate the primary health care system in the country. Again differing standards of expectations, logistics and reimbursement mechanisms need to be sorted out.
In this context, the MMA welcomes the statement by the Prime Minister in his opening of the Kampung Kerinchi 1Malaysia Clinic yesterday, that ....”cases from here (1Malaysia clinics) will be referred to them (private doctors) for further examination or treatment...” and we hope that this will be implemented as quickly as the 1Malaysia clinics have been set up.

MMA Expects Greater Consultation & Shared Purpose for the Way Forward

Perhaps, less appreciated by government and MOH authorities is the fact that health matters and policy changes affect many sectors, including healthcare providers led by doctors, who should be the natural partners for consultation and engagement for the greater good of the public, the rakyat. The MMA is ever ready to be steady partner for working closely and supportively with the MOH, but we must not be taken for granted.
The MMA is not arrogant, although at various times, we have been accused of being too placid by our increasingly demanding members. We have been trying very hard to work with the MOH over many matters of shared interests—during the increased outbreaks of dengue fever, and the H1N1 influenza, we have been tireless supporters of many MOH initiatives which are not universally shared by some sectors and the public. Together, we believe the end results have been much better than we had feared despite initial uncertainties. Our rakyat’s overall confidence without panic seems to be the final result, which benefits all Malaysians. The pandemic flu second wave appears so far to have been kept in check.
Sometimes our differing methods of implementation may appear to have crossed purposes, but this is mostly due to misunderstanding and lack of communication. Although because of the rising doctor population, our percentage representation has declined to around 32%, the MMA still represents sufficient doctors in the country, in fact it remains the largest representative body for doctors with the longest and arguably the most dependable history of doctors’ interests and health concerns.
Although not always evident, most doctors do depend on MMA’s leadership to articulate some physician concerns, which are not so easily conveyed to the authorities. As civil and government servants, public sector doctors are bound by government orders and hierarchical levels of authority which implicitly gags many from raising legitimate concerns and criticisms. MMA thus fills in this unenviable void to voice concerns and doctors’ interests, without fear or favour because that is our remit, although this may sometimes be seen to be irritating and perhaps too ‘garang’.
We recognize that the government and MOH policy makers need a degree of autonomy to enact certain regulations and laws, but without adequate and proper feedback from the doctors or stakeholders on the ground, the implications might be unforeseeably difficult. Indeed many regulations are now seen to be fraught with real-life difficulties and incongruities, which have to be modified and streamlined.
The MMA believes that no authority or government can produce perfect policies, laws and legislations; we can help modify these regulatory frameworks, which ultimately work best for all concerned, in a win-win approach—we and other physician groups, should be engaged and consulted with, for the best cooperative approach to enhancing our healthcare system.

GP Woes are Real and Mounting

Many other problems remain to be resolved, which cannot be achieved by any party alone. Our private sector doctors and GPs are also concerned with many other competing issues such as feeder clinics, wellness health screening centres, pathology laboratories posing as clinics; MCO, third party payer or insurance discounting and selection, etc.
There are also rising complaints and perceived sporadic harassments from MOH officers implementing the PHCFSA, although these are supposedly for guidance for existing clinics, as was the understanding with previous Ministers of Health. Such pressures make the beleaguered GPs very sensitive to these threats on their practice, they seem to have been assaulted from all angles, with more coming on-stream, even before the other has gone away.

Glut of Medical Graduates Coming Sooner than Later

With the rising number of medical graduates, there is genuine fear too that very soon even the MOH cannot sustainably employ all these doctors. There would simply not be sufficient posts for the coming glut of doctors.
By 2015, there is a real possibility that there would be some 40 to 45,000 doctors. Some 1200 to 1500 medical graduates are graduating from our 23 local medical schools. Another 1000 or more foreign trained doctors are returning yearly, and these seem to be rising with each passing year.
Where will these doctors go to practice? Will the public sector be able to absorb all these doctors? We are already experiencing oversupply of house officers in all our major hospitals this year with some of these young doctors having to share a patient, and some departments allowing them to do shift work, quite unheard of before in the past!
Will the GP sector too be saturated in due time? Will there be any moratorium to stay the production of so many doctors, at least within the country? Will we become a diploma mill for medical graduates who would no longer have any career certainty of employability? Would we be following the path of the Philippines, Indonesia or India where surplus doctors have retrained to become more sort-after nurses to work in first world countries, This would be a great waste of our resources and severe drain of our citizens hard-earned savings.

Greater Challenges ahead, Let’s work together

We urge the MOH to work with the MMA to recognize and address the many legitimate concerns of the medical practitioners in the country that are mounting. We have to develop a much more refined and planned system of health care and all its encompassing concerns and provider needs.
Otherwise a potential crisis of unimaginable proportion could arise, which could unleash even greater problems both for disgruntled healthcare providers including very expensively trained doctors, who may have too little to do or even unemployed!
Let doctors have greater and more meaningful input to help resolve some of these issues to help bring about the best health care system for our country.

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