Tuesday, January 19, 2010

President's Page Berita MMA Jan 2010: MMA’s Concerns & Reservations regarding the 1Malaysia Clinics

MMA’s Concerns & Reservations regarding the 1Malaysia Clinics

Dr David KL Quek, President, MMA

MMA's ‘Unpopular’ Viewpoints

There has been a raft of adverse public opinions raised by some writers, including MOH officials, in effect questioning why doctors are so venal and self-serving that they oppose government’s efforts to reach out to the poor, especially the urban poor, with the recent opening of the ‘popular’ 1Malaysia clinics.
The MMA and I personally, have also been vilified as agents provocateur in opposing what is generally viewed as a beneficial move of helping the poor gain ready access to such facilities at such remarkably affordable rates. 
Unfortunately, such views are sadly off the mark and miss the points why many among the medical profession are unhappy. I will try and explain the scenario better, so that more people can understand the realities behind our angst.

As MMA President, MMA’s Roles for Public and Private Doctors

First, I am very mindful that I have been elected to represent all doctors of Malaysia, whose views and professional matters must necessarily fall on my shoulders. Sometimes weighing personal viewpoints against the counter demands of various dissenting doctors can be convoluted. However, when doctors’ concerns and interests appear to be ignored, it must be MMA’s responsibility to highlight, especially when these are perceived to threaten their livelihood or practices.
In fact, GPs form around 40% of our MMA’s membership, 40% from the public healthcare service doctors, and another 20% from the specialist groups.
We too have been fighting for the betterment of work conditions, perks and remuneration for our public servant doctors, lest this is forgotten. Indeed the recent hike in special allowances, tax perks and promotion exercises have been the long-standing joint efforts of the MMA and the enlightened Director-General and Secretary-General of health, and the Nation’s Chief Secretary (KSN), who saw it fitting that we have to reward these doctors better to encourage them to stay within the civil service.
Just these last few months alone, more than 6000 junior doctors in the public health sector got promoted from U41 to U44 grade, and some senior specialists have been promoted to JUSA C grade, which we extol as timely and certainly encouraging.
Thus, it is a disservice to say the MMA is only looking after the private concerns of doctors. We are empowered to pursue proactive actions as part of our role in maintaining and strengthening our professional interests for all doctors.
To further imply that the MMA had made rash judgements is inaccurate. This polemic possibly serves to justify the policy decisions that the authorities had elected to enact. Our earlier press statements have all been made after due diligence and care while double-checking with more than a few unimpeachable sources.
Surely, it is understandable that every profession or work group in the country could occasionally come into cross-purposes with the authorities, the regulators and the government. Such is the dynamic of society and its people.

MMA’s Responsibilities & Robust Response

Which profession or professional body can abdicate from such a position or task? But this should not be misconstrued as selfish and greedy objectives or policies. It is grossly unfair to assume so, when the reality is so different.
I dare say that most if not all doctors whether the GP or the medical officer in the government clinic, have the patient’s interests first and foremost. We unabashedly promote this approach all the time and have urged our doctors to remain faithful to their Hippocratic oath of empathetic service and caring public duty.
Doctors are an integral part of our professional workforce, perhaps a little more privileged than others. Many students and parents also aspire for themselves or their children to pursue such a noble profession, usually at huge family expense, sacrifices, very hard work and dedication. Most of our public here and abroad still views the doctor as arguably the most trusted and respected, as shown by many public opinion polls.
Indeed, it is with profound consideration that the MMA through me as spokesperson, have to articulate some unrecognized but uncomfortable concerns. But we are not actively or purposely working against the public interests. If anything, we have always been our patients’ strongest advocates.
Neither are we picking a fight with the MOH officials with whom we have always been working well together. But sometimes, there will be issues and implementation of policies or practices which we would have to disagree with, and which we would need more robust interaction to resolve in the best possible way. Perhaps then, we can be heard more closely, and our viewpoints recognized as legitimate and fair.
Clearly, some policy decision making from the authorities may sometimes clash with the perceived wisdom of our doctors and perhaps the very acts of medical professionalism itself. We have to reserve the right to disagree, but hopefully without too much rancour or recrimination, so that our professional and practice issues can be better highlighted and perhaps protected.

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, the marginalized, and the underserved, whether in the urban or rural locations.
We fully support every effort to ensure that the poorest among us, as also of every resident 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: Many Doctors Confused and Angered

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 appears redundant, because we already have so many GP clinics in almost every town and suburb 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 trivial and inconsequential to some of us. There has been much anxiety and confusion among many GPs from all over the country.
I have received literally, hundreds of angry and condemning sms’s, faxes and emails demanding that the MMA address this issue, which GPs 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 unpopular Private Healthcare Facilities and Services Act and Regulations (PHCFSA).
The major peeve 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, periodically.
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. Many GPs continue to feel strongly that these clinics should not have been opened and manned in this manner.

No Real Doctor Shortage, Better Deployment the Answer

MMA believes there is no real shortage of medical doctors, but a misdistribution of resources. 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 locations. Yes, despite all the improved perks, retaining doctors in the public service remains a challenge.
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.

Upgrade all Health Clinics, even for the remote and rural areas

Even rural or suburban ‘klinik kesihatan’s can and should be upgraded to doctor-manned clinics which would enhance the overall standard and quality of care for everyone, urban and rural. What we are saying is that these services even for the poor, can be made even better with clinics, which are doctor-covered 100% of the time.
We do not and have never any intention to antagonize or belittle any other related professional group, but the reality still cannot be denied. We are sorry if MAs or nurses felt that they have been belittled. That is furthest from our minds, as we have always recognized their contributions and roles.
However, these personnel whom we all deeply respect and are dependent on, are specifically-trained and have defined scopes of practices, which are as stated quite explicitly, to ‘assist’ doctors to carry out healthcare services, and never intended to replace doctors.
Thus, the specific roles of allied health personnel will not be eroded, but instead should complement those of doctors. It is a norm that doctors should remain in this day and age, as the minimum standard of care, where indeed possible.
We cannot always look backwards in time and compare the 1960s and 70s, where because of our fledgling healthcare service then, we had to utilize these medical assistants, assistant nurses and midwives to provide very critical services, especially in rural and remote areas around the country. Then, quite obviously some kind of healthcare service is better than none at all, and these have served us very well, indeed.
Our maternal and childhood mortality and morbidity data underscores the success of such a much-lauded program, which are being emulated by many other developing nations. We are rightfully proud of this.
But, despite such strides, our health vital statistics still lag behind more advanced countries, which suggest that more improvement can still be achieved. We need not look far, but a check with our Asian neighbours, would show that many have all greatly improved health statistics, certainly better than ours.
It is acknowledged that some nurses have now degrees, Masters and even PhDs, but the reality on the ground remains that these are few and far between. Furthermore it is well-known that these well-trained personnel are usually administrative and not deployed to service health clinics. However, it remains incontestable that their training does not equal that of a doctor’s.
Nevertheless, we fully support the Malaysian Nurses’ Association’s call to further upgrade the calibre, responsibilities and training of nurses in the country. This will undoubtedly enhance the standard of care for all Malaysians.
However, there are also rising concerns that the mushrooming nursing colleges around the country has also cast a growing cloud of ambiguity as to the average quality and standards of our nurses trained recently. This is also true of our many medical schools!
This is the hard truth, which our health system must learn to address before they become unmanageable. But do we dare ask these difficult questions? Is any one authority seriously looking into this, or are we just too comfortably complacent at simply getting out the numbers?
Thus, the MMA maintains that all of these clinic services are best fully supervised directly by a doctor in proximity, in every healthcare establishment. This practice of having surrogate allied health personnel should always be a stopgap measure, which should be discontinued once sufficient efforts were made to enhance our services.
Using such alternate substitute personnel to replace doctors would never be allowed in any of the private hospitals or private medical facilities. So, clearly because of real life shortages and economic factors, we resort to such practices. But in an ideal world, these would not be the preferred choice.
So should we be stuck in the past, or have we to move forwards? Although the Ministry of Health and many other people feel differently, the MMA believes that we can have sufficient doctors to be deployed to service clinics around the country, notwithstanding logistical problems such as doctor reluctance to be deployed to more remote locations, and the continued attrition of public doctors to private sector ventures.
We are convinced that we are now producing sufficient number of doctors (at very expensive rates!), and they can now hopefully function in their true capacity and training to oversee and run these clinics. That is the premise of the MMA and most doctors—we should not compromise on this, simply for economic or other purposes.
Surely if all else are equal, if payment for service is not the concern, who would any one sick person prefer to see, a doctor or another healthcare professional?
This is not to say that there cannot be a complementary assistive role for allied health professionals. Nurses, nurse practitioners, medical assistants, special technicians, physiotherapists, all or some of these, are indispensable and would enhance the overall healthcare experience.
Our premise is that to each professional, its own tasks and duties based on its specific capacity and training. However, this does not mean we are disparaging or looking down on these very important personnel, whom we work with on a daily basis! We must not allow blurry accusations of the MMA from distracting us on the real issue at hand.

Question of Double Standards of Legal Implications of Clinics

Almost every doctor who had complained, believes that this approach of using clinics to be run by MAs and nurses alone, is wrong in law. Our Medical Act dictates that registered doctors should run any health/medical clinic 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 ignored! (It is true that under the Medical Act, the Health Minister can waive or exempt certain regulations.)
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 doctors have openly asked why they too 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. Therein 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. Blatant double standards are badly frowned upon by well-reasoning people, including doctors!
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 registered doctors. We believe this will help defuse the situation, and more importantly will enhance the quality of care for patients.
It should not be that if one is poor, then one has no option but would be serviced by whatever is offered at the cheapest mode. Such inequity exacerbates social injustice and is an affront to modern human rights concerns.

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.”
Another study published in 2008 by the Institute of Health Systems Research (comprising researchers from both University Malaya and MOH doctors), on “Medical Error in MOH Primary Care Clinics”, had also found many more errors hitherto unexposed to the public. Of 1753 clinical records reviewed by a team of family medicine specialists, a very high percentage of medical errors were discovered: 57.2% occur in primary healthcare sites, and 93% of medical errors were deemed preventable. The majority of medical errors are related to medication. Medical assistants saw 81% of the total of records assessed, and thus were responsible for the majority of these medical errors.
A lack of knowledge and skills of MOH staff has been shown to contribute to medical errors. They concluded that there is a need to improve the quality of healthcare services provided by MOH health clinics.
Therefore, safety issues must always be considered. This is not to say that doctors cannot make such similar mistakes, but with far more comprehensive training and education, doctors are expected to make fewer of these errors. Medical protection 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 move also 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.
Lest doctors be lambasted as ‘elitist’ once again, we declare that we are not. But we respect standards and clear task demarcations, which define one profession from another. Task separations have been mankind’s refining benchmarks for better and more specialized work designations, and we believe this approach is particularly appropriate for the medical and health profession.
Importantly, MAs and nurses 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.

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 highly competitive, even excessive and oversupplied. Many clinics have 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.
But MOH concerns that some or most GPs are of unsure/unsound standards are unfounded and biased. Otherwise how is it that some 62.1% of Malaysians who need medical treatment, seek private primary care consultations in the first instance (2006 National Health and Morbidity Survey)?
The MMA is leading a primary healthcare workgroup to further 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.

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; Managed Care Organisations, third party payer or insurance discounting, capping 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.

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 a steady partner for working closely and supportively with the MOH, but we must not be taken for granted to agree with the MOH’s every decision.
The MMA is not arrogant. Conversely at various times, our increasingly demanding members have accused us of being too placid and accommodating with the MOH. 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. The MMA still remains the largest representative body for doctors, with the longest and arguably the most dependable history of doctors’ interests and public 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 to implement. Indeed many regulations are now seen to be fraught with real-life difficulties and incongruities, which have to be modified and streamlined, as an after sight.
The MMA believes that no authority or government can produce perfect policies, laws and legislations; we can help shape and 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.

Greater Challenges ahead, Let’s work together

We are all for better medical services for the public and we are certainly very sympathetic to the poor and those who have been marginalized.
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.
Let doctors and society 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.

1 comment:

drwati said...

Good day Dr Quek

Very good article from you (though i doubt many doctors have the time to read it).

the idea on utilizing GPs to manned 1M clinics is a brilliant one.

another worrying point with the 1M clinic is the long chain of referral (MA to nearby MO to A+E)