Saturday, May 15, 2010

Reflections on another year, as we approach 50…

Reflections on another year, as we approach 50…
Dr David KL Quek

“…This labour, by slow prudence to make mild
A rugged people, and thro' soft degrees
Subdue them to the useful and the good…
…The long day wanes: the slow moon climbs: the deep
Moans round with many voices. Come, my friends,
'T is not too late to seek a newer world…”
~Alfred Lord Tennyson, Ulysses (1809-1892)

The year has flown by, quite literally. Having just taken on the mantle in June last year, I must admit that it has been a breathless rollercoaster experience.

Perhaps what now rankles me somewhat upon reflection is that I wasn’t able to do many of the things that I had envisaged, planned or even hoped. I know I began my term of office by outlining an ambitious plethora of ideas, which now seem almost impossible to fully accomplish, at least not yet.

But I believe, we did manage to at least embark on almost every one of these issues, even if the solutions are unfinished. At the very least, there is that one more year to consolidate on our gains, and to put in place, what we had begun with tentative steps. Clearly too, there is so much work left to do and to continue to proceed collectively.

Still, the flurry of activities and circumstances, which has unfolded have kept my term thus far quite preoccupied. It is clear now that some of these can’t really be predicted, and are more or less foisted upon us by happenstance rather than by foreseeable plans. I suppose having to act and react rapidly and yet judiciously, have defined to some degree what the current mood of the MMA has been under the current Council and my concept of leadership.

So what have we achieved this 11 months or so? I will discuss just some major points of impact for this issue.

Engagement with the MOH, sometimes discordant…
Perhaps one of the more important actions that I have taken is to personally engage more openly and consistently with the Ministry of Health and its officials. We have been participating in many dialogues and planning committees to resolve a myriad of issues. It is not that we have not been meeting them before.

Indeed, many of our predecessors, past presidents and executive committee members had met with MOH officials countless times before, and many issues had been discussed, and some tentative agreements made. But somehow many of the issues and concerns almost always appear remote then but far more urgent now than previously, perhaps because many of these are now coming to a boil, e.g. the 10th Malaysia plan and the proposed healthcare restructuring plans.

Of course we did not always see eye to eye with the Minister or the Director-General on all issues, but through our constant input we have managed to robustly present our viewpoints and our misgivings more directly. Perhaps seen in the cold light of the present, these issues appear more serious and their implications so much more pressing and current.

The 1Malaysia Clinics being manned by paramedical staff remain our major point of disagreement, which we feel undermines specifically the private GPs’ position, but generally the role and position of doctors nationwide, vis-à-vis primary healthcare services. We understand the political and social need to have more accessible clinics for the urban poor, but we disagree that this is the best possible way forward. We still believe unreservedly that doctors should be brought into the picture. Perhaps, the many urban located GPs should have been involved in this exercise to enhance primary healthcare services for these less endowed people.

We hope that with the greater number of medical graduates now available in the MOH, the authorities can deploy fully-qualified medical officers to cover all such clinics including the klinik kesihatan’s throughout the country, urban or rural, in the near future. Some of our GPs now having registered with the MOH should also help to lessen the purported shortage in some of these public clinics throughout the country, and contribute to society in just these critical areas.

We recognise that policy directions and decisions are often so theoretically biased or conceptually incomplete, that some of the more pertinent and practical aspects can become lost in the actual translation. These became points of contention when we were trying to present a concerted approach to containing and modulating the A/H1N1 influenza pandemic.

Communication Barriers remain
Communication down to the grassroots public or even our healthcare providers/officers proved to be disjointed and incomplete no matter the best intentions and the purported use of the mass media. So too were the injunctions to be more vigilant about the resurgent dengue epidemic, which continue to inflict some troublesome and mounting death statistics!

There are still pretty big gaps in our communication access with our members, our doctors out there. Our monthly Berita MMA is clearly too slow, as a medium to transmit urgent messages to our members, especially when events evolve at sometimes breakneck speed! However, this remains the best chronicle for our members. We have to find a better mechanism to reach out to all our doctors and members more consistently, so that all of us can be on the same page, so to speak.

Unfortunately too, our MMA website is still not up to par and is not a favoured regular site of access for most of our members… We are making improvements through a grant from MIDA, but the actual rollout would take some time to meander through its teething problems. For that matter, our MOH website is also not a guaranteed hit for the public or the doctors to access at will!

Would it be possible to utilize tweets or twitter to reach out to our members in due course? Perhaps we could explore this soon, but getting every member to register with us is proving difficult if not impossible, even as we encourage emails at the present time.

With regards to the mainstream media however, it is clear that we are not that newsworthy iconic association that the mass media finds interests in, consistently. The conventional mass media has been less accommodating than we had hoped—they have been piecemeal in reporting on our press releases, opinions or even rebuttals, and therefore have made our tasks so much harder.

Worse, the mass media has a predilection for exaggeration and slanting our viewpoints this way and that, to suit their own agendas, or to sensationalise their own bias, and sometimes even to provoke the authorities, with the MMA being used as a convenient punching bag!

I have tried to resolve this by creating a Facebook MyHealth Matters MMA 2009-2011 site for easier communication for all doctors wishing to log in, but to date the numbers registered remain small, just over 115 doctors and medical students, those actively contributing even fewer…

PHCFS Regulations/Fees—Amendments on the way…
Behind the scenes, we have had numerous (almost monthly this year) meetings with the Amalan (Practice) division of the MOH to modify and resolve the numerous less palatable articles and clauses of the Private Healthcare Facilities and Services Act and Regulations.

We have resolved to remove the very severe punitive measures such as jail terms and excessive fines, and are offering in its stead compound fines for non-compliance of minor technical issues. We have also resolved to remove purely technical infringements from being labelled as egregious breaches of the regulations or law.

We are now embarking on refining the fees schedule, which has proven to be particularly contentious with third party payers and insurance companies. Although we have stated that we would prefer this schedule to be removed from the regulations, the Ministry has categorically rejected this suggestion.

Our 5th Schedule (tendered in since 2008) is unfortunately delayed due to concerns of costs inflation and disagreements with certain specialty societies, but we continue to urge that it be incorporated and updated soon, after some discrepancies have been ironed out. It is useful to remember that the latest schedule in the Regulations was based on our MMA rates first tabled in 2002! It is already 8 years old and the health insurance payer companies are still fighting to reduce and limit our fees! Greater detail in the itemizing of the schedule of fees would help remove misinterpretations and arguments as to the spirit of the fees chargeable by doctors. This aspect has been severely lacking in the adoption of our schedule into the current PHCFS Regulations.

Various Dialogues
Other important areas where we have been active in having important dialogues include our National Health Restructuring/Reform and Policy (1Care). We have had several discussions with officials from the MOH as well as various divisions of the EPU of the PM’s Department; trying to clarify uncertainties as well as grassroots concerns from a professional standpoint.

We have voiced our growing concern that a single-payer healthcare system although ideal is currently fraught with many obstacles, the chief of which is the funding mechanism, which has to be resolved with every stakeholder buying in. This means every citizen, including the healthcare professionals.

We had discussed widening the contribution base for every working citizen, and not just the taxpayers. Under the present circumstances, we foresee deficiencies that would not make feasible this national healthcare reform, what with the government cutting back on allocations and paradoxically expecting the private sector to raise their stakes.

Furthermore, when trying to implement the concept of primary healthcare-led initiatives, do we have the mechanisms for an integrated, portable and yet safe confidential health recording system and the appropriate sharing of health information, including reliable methods of disbursing funds?

We have also had discussions on the Healthcare Liberalisation plans now in place from 2010 (Mutual Recognition Agreements, ASEAN Free Trade agreements) where we managed to get some MIDA grants to enhance dissemination of this initiative.

MSQH: Deviated Approach (?) and GP Accreditation Woes
Perhaps one of the most worrisome plans that the MMA had to rein in the brakes and forestall this year, is the planned Accreditation programme for medical clinics, advocated by the Malaysian Society for Quality in Healthcare (MSQH).

Although this programme was supposed to be voluntary, exercises such as these have a ‘covert’ way of becoming “standards”. The MMA fears that this accreditation move could become institutional barriers to limit entry into schemes for involvement in employee benefit clinic panels, insurance buyers or even being considered part of our future integrated primary care system. As such, the MMA could not agree to be partners of such measures, which would shrink the autonomy of doctors, particularly those in private practice.

Although the MMA is an initial founding tripartite partner of this society (with the MOH and APHM); over the years since 1998, some of us in the MMA’s current leadership feel that MSQH has evolved into an unrecognizable entity, where our role has, to put it bluntly, been marginalized and our influence negated.

Part of this is our fault, the MMA then did not take this society too seriously, but then again we had failed to recognise the deviation from its original ideals and objectives. While we did have different representatives taking part in various subcommittees of the MSQH, the actual impact of some of the programmes discussed have not been fully addressed. As such, until perhaps this fiscal year, there have been tacit but less than informed approvals of what has been transpiring and planned.

Because of this, the MMA feels that the MSQH has deviated from its original aims. It is arguable how this society has become transformed into a corporate entity, where non-medical professionals have a larger say and sway than perhaps the MMA and the doctors who are on the receiving end.

If as is stated that we actually co-own this as a third partner, how is it that there are individual and corporate members, every one of which, carry equal weight and voting rights? Is this a public society and if so, how should its influence and powers really be vis-à-vis the authorities and the MOH? Is the MSQH now a for-profit body where individuals or corporate bodies can buy a stake for potential returns later?

What then is the actual role of the MMA if we are just to rubber stamp the legitimacy of being involved in the closed-door strategic planning and discussions, which could potentially constrain the medical profession even more? Aside from being just one of the many ‘dialogue partners’ and officers who actually work to fine tune the accreditation framework, what really is the gain from MMA’s involvement in the MSQH? There are clearly no financial returns thus far, despite our contribution of RM 100,000 towards the original seeding fund.

How will our members and doctors benefit? It is not enough to suggest that the MMA should serve as a professional guardian to upkeep and raise the standards of healthcare for the nation—these objectives can be met from different approaches, but not at the expense of our doctors. We already have the PHCFS Act and Regulations, do we need more?

The MMA believes the MSQH should be restructured to reflect the original honor system of its 3 main protagonists, with each having equal and executive say; otherwise, it is pointless to continue. Having a designated vice-president position for namesake only is totally inadequate, and reeks of seat-warming representation.

Are we ultimately in the guise of furthering standards in healthcare practices, pushing for greater micromanagement scrutiny and checks for our healthcare provider? Would this additional burden on the clinics enhance our care or simply corrode our practices even more, especially when there is no incentive or return of investments for some of these so-called clinic enhancement measures? Are we enriching some independent entity in a manner that is not altogether clear to us at present? Many questions remain to be asked.

Therefore, it is perhaps time to reappraise our relationship with the MSQH, because it is difficult to fully support its objectives as it now stands, or the direction where it is heading. Together with other medical professional groups such as Academy of Family Physicians, PCDOM, FPMPAM, etc. we are extremely concerned and uneasy about its potential reach and policies. We will need to reconcile and relook into this relationship very soon.

50th Anniversary & our Caring Physician Ethos
As we ponder on the 50th Anniversary of our national MMA, many challenges continue to emerge, which will test the mettle of the medical profession. As outlined above, we face a host of problems concerning professional practice with: the PHCFS Act and Regulations; 1Malaysia clinics; GP uncertainties; mounting insurance and third party payer queries; accreditation plans (MSQH) for GP clinics; better MOH perks, wages and benefits for our public sector doctors; but worries of too many medical graduates and their possibly inadequate training and standards, have recently raised quite a few eyebrows; etc.

Therefore, as medical professionals we must endeavour to remain relevant and professional as we become more effective and efficient. We must also interact with our more discerning and empowered patients in a better, kinder and a more caring approach to enhance each and every patient-doctor encounter. Public expectations certainly demand this paradigm shift toward a more caring and empathetic relationship. The days of the aloof, patrician, paternalistic doctor-knows-best style, are passé.

For most of these critical issues, we need to engage the authorities to help find workable solutions, which will enhance rather than ultimately cripple our healthcare system or make our medical practices unbearable and demotivating.

Greater Physician Involvement: Leadership Needed
But we also need physician leadership to continually take up the challenge of inputting practical on-the-ground misgivings/problems so as to help modulate the theoretical constructs of overview-type changes, which the MOH has deemed necessary to bring about.

I know I have said so many times before, and I wish to repeat this again: we need more doctors to come forwards, to become more involved, be more participatory and engaged to help move our health system forward in a modernisation exercise which would lead to first world standards and universal access to healthcare for all our Malaysian residents and citizens.

We cannot simply remain within our comfort zones, and hope that reforms and changes would simply wash over us. This will not do, because, the impacts will be greater and could even be life changing. Our livelihoods are at stake! Doctors must be willing to come forwards to protect our own professional interests, while we help look after that of our patients. We cannot abdicate this role to others!

This is not to say that we gratuitously disagree or oppose the many important reforms that the government and the MOH are trying to implement. In fact we laud the MOH for its continuous efforts to improve the standards of healthcare and their unapologetic patient safety concerns. Indeed, we are always ready to fully support these reforms for the betterment of our healthcare system, but we do need to be partners of this ongoing dialogue.

Why is this important?

Because, doctors within the MMA whether we like it or not, are the most vocal and arguably the largest representative body of healthcare providers who are best placed to help recognise inconsistencies and glitches in national policy programmes and directions.

Because, I believe that many of us are concerned public advocates (despite our ingrained vested professional interests), who can stand apart and give the better, disinterested input. We are not simply yeah-sayers. We are at the forefront of our healthcare concern and are better placed in many ways to help resolve conflicting and teething problems of real-life practice, not always foreseen by regulators and policy makers—e.g. the potential glut of medical colleges and graduates is one serious point in question.

As medical professionals, we must learn to be more interested, more participatory, to work together as a team in creating more awareness about healthcare issues. We must actively encourage the Malaysian public to get more involved in its own healthcare. We must also engage more robustly with the authorities to help realize a better healthcare system for Malaysia. We cannot afford to become fragmented and weak, so that our voice becomes muted and inconsequential.

We must encourage greater public discourse and debate about our future healthcare plans, funding and reforms; and how these would potentially impact on the public and even on us as medical professionals.

As we enter into our Golden Jubilee, the MMA must become more relevant and consequential! There is much to do, so little time, but together I believe, we can make a better difference for our Malaysian healthcare.

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