Why more primary care may not improve health care quality... by Maggie Mahar

Why more primary care may not improve health care quality

by Maggie Mahar

The emphasis on primary care as the “key” to lifting the quality of U.S. healthcare may be exaggerated according to a report by Dartmouth’s Institute for Health Policy & Clinical Practice.

“Primary care forms the bedrock of a well-functioning, effective health care system,” the researchers observe. But– and this is an important caveat- “simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage, may not be enough to improve the quality of care or lead to better outcomes.”

Wait a minute. In past reports, didn’t Dartmouth’s researchers tell us that patients fare better if they see fewer specialists and more internists?


No.  Dartmouth’s earlier studies have shown that when patients see more specialists, care is more aggressive and more expensive, but, on average, outcomes are no better—and sometimes they are worse. This, however, doesn’t mean that primary care, by itself, ensures better care, even if a patient sees her PCP on a regular basis.

As the report points out: “Primary care is most effective when it is embedded in a high-functioning system, where care is coordinated, where physicians communicate with one another about their patients, and where feedback is available about performance that allows physicians and local hospitals to continually improve.”

Policy should “focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals,”  says Dr. David C. Goodman, lead author and co-principal investigator for the Dartmouth Atlas Project.

That said, the  study’s authors (Goodman, Brownlee, Chang and Fisher) agree that primary care is essential: “Primary care clinicians, whether they are general internists, family practice physicians, pediatricians, physician’s assistants or nurse practitioners, are trained to care for the whole patient.

They can diagnose and treat a wide variety of illnesses, help patients avoid getting sick, and ensure that they get the specialty care they need. For chronically ill patients in particular, primary care clinicians serve a crucial role as coordinators of specialty care. They can also help patients control symptoms, slow the progression of their disease, and help manage acute and chronic conditions without resorting to hospitalization.”

But while primary care can do all of these things, this does not mean that it does.

Geographic variation
This new study surveys access to primary care—and use of primary care— among the fee-for-service Medicare population in different regions of the country from 2003 to 2007, only to find, once again, that geography is destiny.  As the map below reveals, Americans in some parts of the U.S. receive far more primary care than others.  During the report period, the share of patients who saw a primary care physician on an annual basis ranged from roughly 60 percent of beneficiaries in the Bronx, N.Y. and Manhattan to nearly 90 percent in Wilmington, N.C. and Florence, S.C.—about a 50 percent difference.


More primary care does not guarantee better management of chronic diseases
Yet, here is the first surprise: in those regions where patients have more access to primary care physicians, “this alone does not always keep people with chronic conditions out of the hospital, improve their chances of getting the optimal care recommended for their condition, or improve health outcomes.”

For example, when researchers looked at patients suffering from diabetes they  found no relationship between rates of blood lipid testing and eye examinations and whether these beneficiaries with diabetes saw a primary care clinician at least once a year.

There also appeared to be no connection between rates of leg amputation, a serious complication of diabetes and peripheral vascular disease, and whether the beneficiary saw an internist at least once a year. But a  patients’ risk of losing a leg did vary dramatically depending upon where he lived –the report reveals a tenfold difference in the rate of leg amputation, ranging from 0.33 per 1,000 beneficiaries in Provo, Utah to 3.29 per 1,000 in McAllen, Texas—the town made famous for over-treatment in Dr. Atul Gawande’s 2009 New Yorker story.

The report also found that having an annual primary care visit did not keep patients suffering from diabetes or congestive heart failure out of the hospital.

In this case, was a more than fourfold difference in the rate of hospitalizations among Medicare beneficiaries, ranging from 30.7 per 1,000 in Honolulu to 135.0 per 1,000 in Monroe, La. (This could be tied to the fact that Louisiana boasts more physician-owned hospitals and surgical centers than any state except Texas. Research shows that when doctors own hospitals, patients are more likely to find themselves in one of them.)

The researchers theorize that “perhaps primary care visits aren’t doing more to improve outcomes” because “the patients most in need of this care are not receiving it.”

But another possible explanation seems, to me, more persuasive:  “primary care is most effective when it is embedded within a health care system that allows the coordination of primary care services with those delivered by specialists and hospitals,” the researchers observe.  “Unfortunately, most health care providers in the U.S., including primary care physicians, are not organized to do this; many physicians work in small practices, where there is little coordination of care, and communication among a chronically ill patient’s various physicians is often poor to non-existent. Large delivery systems can also fall short in these areas. The quality of the care provided by primary care physicians also varies widely. As a result, patients in regions of the country where they are more likely to have had a primary care visit are not necessarily receiving higher quality care—or enjoying better outcomes.”

Medical cultures vary widely around the nation. In some places, doctors are more likely to work in large mutli-specialty centers where collaboration is a top priority. In other towns, solo practitioners pride themselves on their autonomy. They may play phone tag, but most don’t use electronic medical records—and if they do, these records can’t “talk” to each other.

It’s not about the supply of primary care physicians
More primary care does not necessarily mean better care.  Perhaps that shouldn’t come as such a surprise. PCPs alone cannot solve the nation’s health care crisis. If we want to keep patients out of hospitals, PCPs and specialists must work together—and they must listen to patients and their caregivers.

If we want to reduce the number of diabetics who wind up losing a leg we should look at the larger problems that affect a diabetic’s ability to manage his disease, putting poverty at the top of the list.  Indeed, the report points out that rates of leg amputation for all Medicare beneficiaries differed by a factor of 10. When researchers took a close look at 44 hospital service areas (HSAs) within a single hospital referral region (HRR)  in Atlanta, Georgia, they found a fourfold variation in leg amputation rates.

“Addressing these disparities in health outcomes will require attention to the full spectrum of health determinants,” they write, “ranging from lower levels of schooling and limited health literacy, to inadequate housing and lack of transportation, as well as lack of access to high-quality primary care that is well-coordinated with specialty care.”

That primary care is not a cure-all probably shouldn’t come as a shock. But the report’s second surprise is eye-opening:  having more PCPs physicians –more general practitioners, internists and pediatricians–does not  necessarily mean greater access to primary care: “Our findings suggest that the nation’s primary care deficit won’t be solved by simply increasing  access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage,” says Goodman.

A shortage of PCPs “may contribute to the problem in some locations,” the report notes, but “there is no simple correlation between supply  . . . and access,” says Dr. Elliott S. Fisher, a report author and co-principal investigator for the Dartmouth Atlas Project.

The study shows that, in some regions, a relatively high proportion of beneficiaries saw an internist at least once a year, even though overall primary care physician supply was low. This includes Wilmington, N.C., where there were 69.0 primary care physicians per 100,000 residents and 87.4 percent of patients had at least one annual primary care visit. Meanwhile, despite an abundant supply of PCPS in White Plains, N.Y. (101.4 per 100,000), less than 70 percent of beneficiaries saw a primary care clinician each year.

Here, I suspect that the residents of White Plains are simply more likely to go directly to a specialist, rather than consulting a primary care physician first. White Plains is a suburb of New York City, and New York boasts an embarrassment of specialists. (I know, from personal experience that I can usually get an appointment with a Park Avenue specialist within a few days—even if I am a new patient.)  Patients in the New York area tend to believe that more expensive is always “better” and of course specialists are more expensive. And while some Americans are wary of “experts,” New Yorkers tend to like the idea of consulting someone at the very top of the food chain. (Many Manhattanites consider themselves experts of one kind or another.)

In addition, primary care doctors in New York, like PCPs in Boston, may keep their waiting rooms crowded by seeing regular patients more often than doctors in some other towns. Again, this is part of the medical culture in Manhattan. If you want to re-fill a regular prescription, your doctor will insist that you come in and see him every three months. If your insurance requires that you get a referral to see an eye doctor, your PCP will tell you that you must come in for an appointment first. Even though he’s not going to exam your eyes, he’s not going to be paid for making the referral unless you see him.

As a result, it’s difficult to squeeze in an emergency—or a new patient.  If you call and say you’re experiencing chest pain, your internist will tell you to call an ambulance and go to the ER. (This happened to a friend recently, and stands as an example of the aggressive, expensive approach to health care that Manhattanites have come to expect. He was fine; it may have been indigestion.)  Boston is much like New York. A friend there told about the time he cut his hand. His internist couldn’t fit him in. His wife’s primary care doctor couldn’t see him. He wound up having his sister sew up his hand on her kitchen table.   My guess is that if my friend lived in Wilmington N.C., and he called his internist, the doctor’s receptionist would say “Come on in—we’ll stitch it up.”

I am, of course, speculating. And these are only anecdotes, but anecdotes can illustrate a medical culture.  In addition, Dartmouth data confirms that New Yorkers see many more specialist than patients in Iowa—though our outcomes are no better.  The problem in New York so much a dearth of internists as the fact that healthcare in New York City is so fragmented:  most of our specialists work solo or in small practices.  They value their independence. Many bristle if hospitals try to suggest “rules” or even “guidelines” for best practice. Thus, most surgeons don’t use checklists, even though there is ample evidence that a simple piece of paper can save lives.

Ultimately, this newest Dartmouth study suggests that healthcare, like real estate, is all about “location, location, location.”  As the authors put it: “This report highlights the importance of understanding health care within a local context and underscores the need to address the underlying causes of  . . . disparities both within and across regions.”

Where you live is paramount
The report acknowledges that both lower-income Americans, and minorities receive less care. Put bluntly, the quality of care you receive varies, depending on who you are.  “On average, blacks were less likely to see a primary care clinician than whites—70.4 percent had at least one annual visit in 2003-07 compared with 78.1 percent for whites.”  

But regional disparities are far greater:  where a patient lives turns out to be even more important than the color of his skin.  “In the U.S. health care system, it’s not only who you are that matters; it’s also where you get your care,” the authors report. “Regardless of race and income, patients receive care of widely varying quality depending upon where they live and the health system that provides their care.”

If you’re very lucky, you live in a place where the medical culture favors “collaboration” over “competition,” a town where general practitioners, specialists, and hospitals understand that medicine is a team sport. Too many primary care doctors labor alone—working long hours without sufficient support.

This is one reason  why being a primary care doctor is so difficult. I recall Dr. Donald Berwick, Medicare’s new director, once saying, “No doctor should be alone.”  The job is too hard. Insofar as there is a single “key” to raising the quality of U.S. health care, “co-ordination” is, I think, the word to keep in mind.

Maggie Mahar is a fellow at The Century Foundation and the author of Money-Driven Medicine: The Real Reason Health Care Costs So Much. She blogs at Health Beat, where this post originally appeared.

Berita Harian: Mekanisme klinik keluarga kurangkan kos perubatan... Oleh Syed Azwan Syed Ali

Mekanisme klinik keluarga kurangkan kos perubatan
Oleh Syed Azwan Syed Ali
syedazwan@bharian.com.my
Berita Harian, 2011/01/05

Kertas cadangan guna model dipraktikkan di UK dibentang Februari

KUALA LUMPUR: Kos penjagaan kesihatan di negara ini dijangka berkurangan apabila cadangan mewajibkan setiap individu melantik klinik pilihan mereka sebagai klinik keluarga di bawah Skim Penjagaan Kesihatan Nasional 1Care dilaksanakan kelak.

Melalui mekanisme yang mengguna pakai model Perkhidmatan Kesihatan Nasional (NHS) United Kingdom (UK), individu hanya boleh dirujuk ke hospital untuk rawatan pakar dengan sokongan doktor keluarga, kecuali bagi kes kecemasan.

Mekanisme itu apabila dilaksanakan kelak akan mengurangkan kos penjagaan kesihatan yang signifikan, termasuk pembaziran ubat dan ujian makmal yang tidak diperlukan pesakit.

Presiden Persatuan Perubatan Malaysia (MMA), Dr David KL Quek, berkata ketika ini, kebanyakan individu cenderung untuk terus mendapatkan rawatan di pusat perubatan swasta kerana tidak sanggup beratur panjang di hospital kerajaan.

“Ini mengakibatkan kos penjagaan kesihatan di negara ini menjadi mahal."

Dengan menjadikan doktor keluarga sebagai ‘gate-keeper’ di bawah skim dicadangkan, pesakit tidak perlu terus ke hospital untuk rawatan,” katanya kepada Berita Harian.

Dr Quek mengulas laporan muka depan akhbar ini, Isnin lalu mengenai pelaksanaan Skim 1Care, antara lain bertujuan meningkatkan akses rakyat kepada perkhidmatan penjagaan kesihatan kerajaan dan swasta mengikut pilihan tanpa mengambil kira status kewangan mereka.

Melalui skim yang menggabungkan perkhidmatan kesihatan kerajaan dan swasta itu, sebuah dana kesihatan nasional yang dibiayai kerajaan (lebih 90 peratus), pekerja dan majikan (melalui potongan cukai, bayaran premium atau kaedah lain yang ditetapkan) akan ditubuhkan untuk membiayai kos penjagaan kesihatan rakyat.

Pelaksanaan skim itu antara lain bertujuan mengurangkan beban di hospital kerajaan dengan menyeragamkan kualiti perkhidmatan, kelengkapan, sumber manusia, caj rawatan dan perubatan antara hospital kerajaan dan swasta, sekali gus memberikan pilihan kepada rakyat mendapatkan rawatan di hospital pilihan mereka.

Difahamkan, kertas cadangan skim penjagaan kesihatan menggunakan model NHS UK sudah disediakan Kementerian Kesihatan dan akan dibentangkan kepada Perdana Menteri, Datuk Seri Najib Razak, selewat-lewatnya bulan depan.

Dr Quek berkata, ada beberapa isu perlu diperjelaskan kerajaan sebelum melaksanakan skim itu, antaranya pelaksanaan integrasi kedua-dua perkhidmatan kesihatan kerajaan dan swasta serta aspek kewangan, terutama mengenai sumbangan individu kepada dana kesihatan nasional yang dicadangkan.

Katanya, kerajaan juga perlu menjelaskan mengenai bayaran bersama yang mungkin dikenakan kepada pesakit supaya semua pihak jelas mengenai komitmen mereka, sekiranya cadangan skim itu dilaksanakan.

Ketika ini, kira-kira 40 peratus daripada rakyat Malaysia mengeluarkan wang sendiri bagi membiayai kos penjagaan kesihatan mereka di hospital atau pusat perubatan swasta.

Pada 2009, kemasukan pesakit ke 130 hospital kerajaan yang mempunyai 33,083 katil adalah 2.13 juta, iaitu 2.6 kali ganda lebih tinggi daripada 209 hospital dan pusat perubatan swasta yang mempunyai 12,216 katil serta menerima 828,399 pesakit.

Lancet (Jan 1, 2011): The Greek economic crisis: a primary health-care perspective

The Greek economic crisis: a primary health-care perspective

The Greek economic crisis has caused global concern owing to its side effects and risks involved for both the eurozone and the global economic community.

Analysis of the problem shows that the major sources of inadequacy are the severe structural weaknesses in Greek public administration, economy, and society, which lead to bureaucracy, corruption, low quality of services, and high costs.

Greek health care is a typical example of a bleeding economic sector. Although the total health-care expenditure rose from 5·3% of gross domestic product in 1991 to 9·7% in 2008, Greece has actually got worse in terms of global health outcomes.1

Why is that? Administrative barriers affect every aspect of the Greek healthcare system, with perhaps the largest insufficiencies located in primary care.2 In general, Greek primary care is highly fragmented, since there are several different public and private providers involved, with no coordination between them and no gatekeeping system.3

Some of the main reasons for the high primary health-care costs are the repetition of tests and prescriptions due to poor information transfer between providers and the vast induced demand for health-care services.

The latter is perhaps the most important factor and can be explained by the large number of specialists—the highest among countries of the Organisation for Economic Cooperation and Development—and the ineffectiveness of the existing control mechanisms of health insurance funds who incur the costs.4

We strongly believe that the above problems could be addressed by ensuring adequate political will and social consensus. The integration of all primary-care providers, the establishment of the multidisciplinary primary-care team, and the enactment of the family doctor institution are necessary to
obtain comprehensive, continuous, and efficient health care.5

The introduction and implementation of diagnostic and treatment guidelines in daily clinical practice could result in a better quality of care and a rationalisation of health-care expenditure. The induced demand for medical services seems an intractable problem, but might be controlled by a reduction in the production of new physicians.

Greece is struggling to manage its fiscal problems, overcome recession, and maintain a social welfare state. To achieve these goals and get out of the crisis, it is time for Greece to capitalise on moral, economic, political, and scientific support from international bodies and advanced nations by making drastic organisational reforms in all aspects of the public sector, including health care.

We declare that we have no conflicts of interest.

*Nikolaos Oikonomou, Yannis Tountas
nikolaos.emailaddress@gmail.com
Centre for Health Services Research, Medical School,
University of Athens, 115 27 Athens, Greece



References:
1 OECD. OECD health data 2010. Paris: OECD, 2010.

2 Tountas Y, Karnaki P. The ‘‘unexpected’’ growth of the private health sector in Greece. Health Policy 2005; 74: 167–80.

3 Mossialos E, Allin S, Davaki K. Analysing the Greek health system: a tale of fragmentation and inertia. Health Econ 2005; 14 (suppl 1): S151–68.

4 Oikonomou N, Mariolis A. Three trends that undermine the Greek health system: is there a way out? Eur J Gen Pract 2009;15: 67–68.

5 Lionis C, Symvoulakis EK, Markaki A, et al. Integrated primary health care in Greece, a missing issue in the current health policy agenda: a systematic review. Int J Integr Care 2009; 9: e88.

Lancet (Jan 1, 2011): When will the sun shine on Cyprus’s National Health Service?

When will the sun shine on Cyprus’s National Health Service?

It has been 9 years since an official parliamentary law was passed in Cyprus to implement a primary care-driven health-care coverage system for the entire population. Since then, the Health Insurance Organisation has been set up as the single payer, which, in collaboration with McKinsey consultants, has brought forth a detailed design for the long-awaited Cyprus National Health Service (NHS).

However, despite the project reaching its final stages, a cloud of doubt remains over whether the government will take the plunge and implement what it has so carefully planned.

Little has changed since a World Report in The Lancet stated in 2005 that “there has not been sufficient pressure on the government to adopt a universal health plan”.1

Cypriot health care is still divided, with 50% of the population using public healthcare services and 50% private health care.

Primary care is underdeveloped, with general practitioners (GPs) comprising only 9·8% of all physicians, and with a decreasing trend.2 This proportion compares with an average of 25·5% for the European Union3 and about 50% for the UK. Patients have often not heard of a “GP”, and certainly not registered with one. Thus, there is commonly no continuity or co-ordination of care. Quality-improvement strategies are lacking.4

The isolation between private and public health care leads to duplication of tests, and of resource use.5 Specifically, the public-sector cost is growing at a double-digit rate, thereby reaching a level in the near future at which the government budget will not be able to sustain it.

Furthermore, direct access to specialists often leads to the patient not having a unified health record; additionally, holistic preventive care often slips through the net. By contrast with other EU countries, Cypriots pay 52% of healthcare cost out-of-pocket (43% of the population pay for private prescriptions).

The new NHS proposed for Cyprus aims at equity in finance, universal coverage, shifting of service provision from secondary to primary care, efficiency, high quality standards, and containment of cost through a global budget. Every person will be registered with a personal primary care physician of their choice. The free choice of specialist physician (public or private) after referral as well as hospital (public or private) will also lie with the patient.

We urge the government to take concrete steps towards implementing the health-care reform—ie, finalise the NHS information technology system and GPs’ training tender—thus moving Cyprus’s health care forward while helping to control health expenditure growth.

We declare that we have no conflicts of interest.

*George Samoutis, Constantinos Paschalides
george.samoutis@ouc.ac.cy
Messinis 3, 2301 Nicosia, Cyprus (GS); and Tiptree
Medical Centre, Tiptree, UK (CP)

References:
1 Antoniadou M. Can Cyprus overcome its health-care challenges? Lancet 2005;
365: 1017–20.

2 Cyprus Medical Association. Registry of medical specialties in Cyprus. http://www.
cyma.org.cy/ (accessed Dec 14, 2010).

3 WHO Regional Offi ce for Europe. European health for all database. http://www.euro.
who.int/en/what-we-do/data-andevidence/atabases/european-healthfor-all-database-hfa-db2 (accessed Dec 14, 2010).

4 Samoutis GA, Soteriades ES, Stoff ers HE, Philalithis A, Delicha EM, Lionis C. A pilot quality improvement intervention in patients with diabetes and hypertension in primary care settings of Cyprus. Fam Pract 2010; 27: 263–70.

5 Andreou M, Pashardes P, Pashourtidou N. Cost and value of health care in Cyprus. Policy paper. Nicosia: University of Cyprus, 2010. http://www.ucy.ac.cy/data/ecorece/DOP02-10.pdf (accessed Dec 14, 2010).

Berita Harian: DANA KESIHATAN RAKYAT... Oleh Syed Azwan Syed Ali

DANA KESIHATAN RAKYAT

Oleh Syed Azwan Syed Ali

Berita Harian, 03 Jan, 2011

KUALA LUMPUR: Kerajaan sedang mempertimbangkan kemungkinan pelaksanaan Skim Penjagaan Kesihatan Nasional 1Care yang antara lain memberi pilihan kepada rakyat mendapatkan rawatan di hospital kerajaan atau hospital swasta tanpa mengira kedudukan sosial dan kewangan mereka.
   

Skim yang akan membabitkan penggabungan sistem pengurusan kesihatan kerajaan dengan swasta itu dijangka mewajibkan rakyat memilih atau melantik pengamal perubatan di klinik pilihan sebagai doktor keluarga dan pesakit hanya dirujuk ke hospital dengan sokongan doktor keluarga masing-masing. 

   Menurut sumber, bagi melaksanakannya, sebuah dana khas kesihatan dicadangkan untuk membiayai kos penjagaan kesihatan rakyat dengan mereka yang berkemampuan menyumbang kepada dana itu melalui bayaran bulanan (premium insurans), potongan cukai atau kaedah lain yang akan ditetapkan.
 

Katanya, kira-kira 90 peratus daripada dana kesihatan itu dibiaya kerajaan, manakala selebihnya disumbangkan mereka yang berkemampuan membabitkan majikan dan pekerja dalam peratusan yang ditentukan kelak.
 

Difahamkan, kertas cadangan skim 1Care yang disediakan Kementerian Kesihatan dibentangkan kepada Perdana Menteri, Datuk Seri Najib Razak, selewat-lewatnya bulan depan untuk pertimbangan kerajaan.
 

Najib sebelum ini dilaporkan berkata, sistem penjagaan kesihatan negara akan melalui proses perubahan untuk menjadikannya lebih efektif dengan  pelan induk sistem kesihatan 1Care for 1Malaysia sedang dikaji secara telus.
 

Sumber berkata, Skim Penjagaan Kesihatan Nasional 1Care sedang dipertimbang secara serius oleh kerajaan untuk menambah baik sistem penjagaan kesihatan sedia ada, bertujuan menambah baik kemudahan penjagaan kesihatan rakyat, selain mengurangkan beban hospital kerajaan yang menjadi tempat rujukan utama.
 

“Pelaksanaan skim itu juga meningkatkan capaian rakyat terhadap perkhidmatan kesihatan pilihan mereka kerana caj rawatan dan perubatan di hospital kerajaan atau swasta diseragamkan melalui penggabungan sistem pengurusan kesihatan. Ini bermakna, caj rawatan dan perubatan tertakluk kepada jadual pembayaran yang akan ditetapkan. Namun, pesakit tidak boleh sewenang-wenangnya ke hospital tanpa disyor doktor keluarga,” katanya.
 

Skim itu dikatakan mirip Perkhidmatan Kesihatan Nasional (NHS) di United Kingdom yang pembiayaan penjagaan kesihatan menerusi dana khas dikumpul sepenuhnya melalui potongan cukai.
Setiap individu di negara itu menyumbang dalam jumlah tertentu untuk menampung penjagaan kesihatan bagi semua pihak tanpa mengira status dan kedudukan sosial. 

Mereka wajib memilih dan melantik klinik terdekat atau klinik pilihan sebagai panel doktor keluarga bagi memudahkan rekod kesihatan dipantau dan hanya diberi rawatan atau dirujuk ke hospital jika perlu. 

 Sumber itu berkata, melalui skim kesihatan itu, bayaran rawatan dan perubatan asas pesakit ditanggung dana kesihatan berkenaan dengan pesakit mungkin dikenakan ‘bayaran bersama’ yang minimum sebagai komitmen.
 

Ketika ini, sistem penjagaan kesihatan negara di bahagikan kepada dua iaitu sektor kerajaan yang ditanggung sepenuhnya kerajaan dengan pesakit membayar RM1 yuran pendaftaran untuk mendapatkan rawatan dan sektor swasta bagi mereka yang berkemampuan.
 

 Ia menyebabkan beban ditanggung hospital kerajaan berlipat  ganda berbanding  swasta, selain kos penjagaan kesihatan negara terus meningkat daripada RM1 bilion kepada 1983 kepada RM6.3 bilion pada 2003 dan  meningkat pada tahun lalu.

The Guardian: Doctors warned to expect unrest over NHS reforms... by Dennis Campbell

Doctors warned to expect unrest over NHS reforms

Exclusive: GPs' leader criticises Lansley's reform plans and predicts that doctors will face demonstrations by angry patients  

by Denis Campbell, health correspondent 

guardian.co.uk, Friday 19 November 2010 21.02 GMT

 

Clare Gerada, chairman of the Royal College of GPs. She predicts trouble for doctors from a public angry at Conservative NHS reforms. Photograph: Frank Baron for the Guardian

Doctors face demonstrations outside their surgeries and questions about their high salaries by angry patients because of the government’s radical NHS shakeup, the new leader of Britain’s GPs warns.   

Desperate patients denied life-extending drugs or surgery for their ailments may also vent their frustrations on GPs, because they are due to assume control of deciding how £80bn-a-year of health funding is spent, said Dr Clare Gerada, who takes over tomorrow as chair of the Royal College of GPs.    

In an outspoken attack on health secretary Andrew Lansley’s NHS reform plans, she also hit out at his decision to transfer responsibility for rationing access to treatment from the National Institute of Health and Clinical Excellence (Nice) and primary care trusts to GPs in England from 2013.     

“At worst, the negative impact for GPs could be patients lobbying outside their front door, saying, ‘You’ve got a nice BMW car but you will not allow me to have this cytotoxic drug that will give me three more months of life,’”  Gerada told the Guardian in an interview.  

“I’m concerned that my profession, GPs, will be exposed to lobbying by patients, patient groups and the pharma industry to fund or commission their bit of the service. There could be letters from MPs and patient groups, and begging letters from patients.”     

Making GPs “the new rationers” of NHS care could ruin the long-established bonds of trust between them and their patients, undermine “the sacredness of the consultation” and turn patients into little more than “customers” who shop around trying to get the best treatment for their ailment, Gerada added.     

Inherent conflicts of interest in the new system could also jeopardise GP-patient relationships, she warned. “Patients might think that the decision made about their healthcare will be based on self-interest – GPs saving money for themselves rather than spending it on patients.” Certain treatment decisions, and a GP consortium’s need to balance its books “could be misconstrued”.     

The NHS will not survive intact Lansley’s plans to scrap many existing NHS bodies, introduce GP commissioning and push through greater competition between hospitals, she predicted. “I think it is the end of the NHS as we currently know it, which is a national, unified health service, with central policies and central planning, in the way that [Aneurin] Bevan imagined,” said 51-year-old Gerada, who represents Britain’s 40,000 family doctors.     

Lansley’s shakeup will lead to a much greater role for private healthcare companies, the likelihood that England’s health system will look more and more like America’s, and GPs being blamed for things such as the NHS’s inability to cope with a winter crisis, long waiting lists and the decommissioning of services to save money, she added.     

GPs in their new role will bear the brunt of the NHS’s need to save £20bn by 2014, which will lead to far more “postcode lotteries” in services such as IVF, expensive drugs, and even access to particular hospital specialists such as surgeons and gynaecologists.   

Leaving each of the new GP consortiums to decide individually what treatment should or should not be available locally will lead to disputes over access to care.  “I don’t understand why he’s putting in a system that in Scunthorpe you can get a different service to Scarborough, when we’ve spent the last 60 years working against that”, said Gerada. Her comments are the most detailed criticism yet made by any senior doctor of Lansley’s plans, which have caused serious unease among medical organisations.    

John Healey, Labour’s shadow health secretary, used them to portray Lansley as dogmatic and out-of-touch. “These criticisms from an influential GP again reveal how Andrew Lansley is failing to listen to the warnings of doctors, nurses and health experts to slow down on his high-cost, high-risk plans,” said Healey.     

“With plans for the biggest reorganisation in the NHS’s history, it is also becoming clear that he is running a rogue department, operating in isolation from his colleagues in government.” Healey echoed Gerada’s concern about patients in future questioning GPs’ motivations.  “Patients will worry about treatment decisions – are they being taken in their best interest or the best interest of the GP consortium’s budget?”  

The British Medical Association warned the changes could see the NHS fragment. Dr Laurence Buckman, chairman of the BMA’s GPs committee, agreed with some of Gerada’s concerns.  “GPs are fully aware of the difficulties facing the NHS as we enter a very difficult financial period and that tough decisions will have to be taken.   

The BMA has repeatedly expressed its concerns about the timing of the white paper proposals as well as the potential risks and benefits that may result from the government’s plans,” he said.     

Prof Chris Ham, chief executive of the King’s Fund health thinktank, endorsed Gerada’s view that Lansley should move more slowly. “With international evidence this week showing our health system performing well compared to other countries, and the NHS facing significant financial pressures over the next few years, evolutionary change building on existing arrangements offers a more promising route to improving the NHS than radical structural changes,” he said.     

A Department of Health spokeswoman said: “Our reforms will indeed mark a new era for the NHS – one where patients and clinicians are at the heart of the service. Our reforms aren’t an option, they are a necessity in order to sustain and improve our NHS. The reforms are far-reaching but they also build upon existing designs.     

We share a common goal with the RCGP that we all want patients to get the best health and care services.” But she added: “We understand concerns around implementation. That’s why we have consulted extensively on our plans, and have already announced a programme where GP consortia can start testing white paper principles. We will announce the outcome of the consultation later this year. We believe that both purpose and pace are vital to improve services for patients.”

Health Reform: Private Sector & GP Role Confusion

Health Reform: Private Sector & GP Role Confusion

Dr David KL Quek

drquek@gmail.com

(President's Page, MMA News October 2010)

“Physicians must become a constructive voice in deciding how health care costs can more appropriately reflect society’s values and needs. Planning for that eventuality should begin now, but cannot be led by a single specialty organization, cannot aggravate the town/gown split in medicine… and cannot be performed in a way that violates the Hippocratic oath. However, it must be done. At the very least, a set of detailed options needs to be developed to contain costs, and physicians should lead the debate about how such options might be implemented. There is no group more trusted in society than physicians. If anyone can lead development of such a plan, it should be physicians.” ~ Robert H. Brook, Rand Corporation[1]

Health Reform Vs. Changing Social Demands & Needs

It has been said that change must be transformational, even radical, if it is to have its most paradigmatic footprint on society that the reformist or revolutionary wishes to leave behind.

Most leaders appear to love these types of change, of wanting to be seen to be bold, novel and innovative, yet impactful and perhaps most importantly, best remembered historically.

Aneurin Bevan has been immortalized as that one socially-driven politician, who had established the National Health Service (NHS) for Britain in 1948, during the socioeconomic turmoil following World War II. Half a century on, its iconic legacy has been contentiously recognised as arguably the most enduring model of health system for the modern world. Even if at times, the NHS appears archaic, and unable to meet the growing demands of contemporary society and its knowledge-savvy citizens.

But even as we continue to debate the NHS’ longevity, the new British government is bent on reforming and liberalizing its lead-shorn laggardness.[2] Command single-payer systems may work but can also become unruly and top heavy. So much so, that demands for individual choice crescendo to become a deafening clamour for better, more efficient delivery of safe and timely healthcare.

Not many ill patients are now willing to resignedly wait their turn, to queue as per economically-dictated rationing. Even if this individualistic preference is achieved at some higher premium costs! Essentially, more and more people are expecting and demanding more personalised rather than uniform factory-style care—impersonal cogs on the grinding wheels of soulless clockwork but cost-constrained efficiency is not enough.

But grappling with societal demands versus economic reality is not always easy, nor entirely logical. There is always that irrational component of wanting more individually, than what is best for the larger good of the many. This applies to healthcare more so than to other social demands or needs. We demand this as of our human right, but also wish upon that seemingly nonnegotiable luxury of timely, proficient, safe and compassionate care.

Paradoxically, no one wants to pay more than he or she needs to, and yet hankers for unfettered access to more and more medical advances. We all want new and up-to-date therapies and indulge in ephemeral dreams of erstwhile longevity or prolonged physical beauty, while at the same time we begrudge rising if unpalatable costs! Governments and policy makers are thus caught in this quagmire of finite resources, limited supply and endless demands.

Private vs. Public sector restructuring

For Malaysia, authorities have once again resurrected plans to restructure our health care system, perhaps this time far more comprehensively, drastically even, than ever before. Thus, in tandem with the slogan-heavy pronouncements of the government of Dato’ Sri Najib Razak, we are now introduced to the concept of ‘1Care for 1Malaysia’ health restructuring.[3]

We have the 1Malaysia, the GTP, the NEM, the recently heralded ETP: Economic Transformation Programmes, hence the current acronym of “1Care for 1Malaysia” for healthcare reform.

To be sure, these plans are now much grander, more re-engineered to fit the model of a marked policy shift both in terms of funding as well as structure. But, coming in the prolonged wake of our widely expanded private sector over the past 25 years, such plans to integrate public-private sectors, cause much confusion and understandably some resistance as to the final direction and form of where our health care system is heading.

Having said this, we are not Luddites who irrationally oppose change for the mere sake of it. We strongly believe there are genuine concerns that many if not most practical aspects of such a huge undertaking have not been worked out satisfactorily. That perhaps, some of these ideas might not be the best that have been articulated, and which might need exhaustive scrutiny and public feedback.

Herein lie some of the unspoken nitty-gritty ‘devils in the detail’—there’s been minimal consideration for practical particulars, but much theoretical and high-sounding huh-hahs and noises. We however, accept the contention by some officials that this is very much “work in progress”.

“Health reform is not only about health insurance companies, physicians, and pharmaceutical and device companies.

It is not only mandating health insurance for everyone… Health reform is about people. And people must become full participants and assume much greater responsibility for their actions if health benefits are to be maintained at an affordable cost.” ~ Richard H. Brook, Rand Corporation[4]

MMA believes that change should not be based on misplaced or erroneous premises. While the privatization approach is contributory and possibly instrumental in the world’s experience of skyrocketing healthcare costs, this is but one dynamic of free-market economic forces, not the one all and be all.

However, the lurking suspicion that private healthcare is the root evil of all healthcare woes is a cynical approach to the dilemma of strategic healthcare planning in the midst of escalating and apparently uncontainable costs.

The MMA wonders if the authorities and the government continue to believe in the free-market and private sector of health care in this country, or is this the start of a determined effort to gradually dismantle the private sector altogether?

This is not to say that we believe in the unbridled rise in healthcare costs to untenable levels, leading to gross inequity in access to the poorer segment of society, or to those haplessly afflicted by catastrophic illness. MMA continues to staunchly believe in and advocate for a sustainable model of universal access to healthcare for all.

It is the ‘how’ and ‘what’ of achieving this, which causes much discomfiture. What’s the final product like? How would this ultimately affect the medical profession and the public?

Thus, the transformation plans must clearly position the roles of the private vs. the public sectors despite the possible move toward a single payer system, where contract purchases of private services could still serve to improve efficiency in the delivery of health services.

1Care for 1Malaysia Health Reform

What is 1Care? “1Care is the restructured national health system that is responsive and provides choice of quality health care, ensuring universal coverage for the health care needs of the population based on the spirit of solidarity and equity,” says the MOH.

Theoretically, such a definition is fully acceptable. It is a neat slogan and concept, but just how this is to be realised is somewhat contentious, with the details being quite unclear, as of now.

More importantly, the question that needs to be asked is, why change, why now, and if so, how?

The government and the MOH has considered reform for some time now, perhaps as long as 15 years according to MOH officials, with inputs from several sources including many experts and consultants the world over as to how we can transform our health system into something even better.

One theme keeps recurring, “Is our current system of an entrenched dichotomous private-public approach sustainable?”

According to our government, this appears not. Healthcare cost is rising and shows no signs of abating as elsewhere in the world. Health care spending has been increasing and out-of-pocket (OOP) payment for health care services especially in the private sector has been mounting.

The proportion of OOP is now around 40%, which mimics the profile of a third world ‘underdeveloped’ economy. Most developed nations have only 20 to 25% OOP in their health expenditure profiles, with the government and the Social Health Insurance (SHI) partaking of around half to two-thirds of the Total Health Expenditure (THE). Unfortunately the Malaysian government contributes just 44% of the country’s total health spending, with the private sector playing catch-up to fill in the void created.

In MMA’s view, the government spends too little on our health care: the government contributes just 2.1% of the GDP to healthcare (from government tax revenue allocations) with the private sector taking up the slack of another 2.7%. Our healthcare expenditure is around 7% of all total government spending, but still accounts for only a paltry 4.8% of the total GDP.[5] WHO recommends at least 8%. Most developed economies spend some 8 to 15% of their GDP on healthcare.

We can do this better. We need greater government commitment to healthcare budgetary contribution, perhaps 4% of the GDP, in order to take leadership and encourage the private sector to emulate these more committed efforts. Together perhaps we can consider expending some 8 to 10% of our GDP for health care.

We agree that we are facing many challenges: we need to a) ensure that our services meet our patients’ needs, b) to enhance our performance to ensure higher quality of care and c) ensure that our healthcare delivery is less sporadic and more equitable, i.e. we need to overcome our limited and mismatched health care resources. However, many are asking: “If it ain’t broke, why fix it?”

A WHO consultant has actually expressed caution when discussing the need for drastic change. According to internal sources, he has recommended the following:

·       More evidence to assess if the benefits of the reform justify the costs

·       More analysis on service delivery aspects of the reform

·       Exploration of ‘partial’ reform options

·       Piloting of different components of the 1Care proposal

Interestingly, in a World Health Report 2006[6] (Working Together for Health), the WHO has found that most Malaysians surveyed had a favourable impression of our healthcare delivery i.e. 88% of patients perceived of having been treated with respect in their last encounter at a healthcare facility.

Importantly for a nation which spends just under USD500 per capita on healthcare per annum, our health statistics are quite impressive: our under-5 mortality is remarkably low, our life expectancy has also progressed remarkably well, i.e. we are above the curve of cost-efficient healthcare ourcomes, although clearly we can do much more to improve our lot!

The GP Misconception & Private-Public Integration Plans

One of the pillars of the touted transformation is the public-private integration plans of the new system, now suggested to take place over a longer spread of time, perhaps through the 10^th to 11^th Malaysia Plans i.e. 10-15 years even.

Here, the overall plan is to move towards a primary care provider-led system, with the thrust towards more promotive-preventive care and early intervention. Family medicine specialists would serve as hands-on first provider as well as gatekeeper function in a totally revamped primary care-led referral system. Payments for services would be via capitation methods and case-mix models, clearly a huge shift to the unknown.

According to our MOH officials, our current crop of GPs would have to be retrained, re-credentialed and ‘upgraded’ to be able to fit into the system, which is one particular area where MMA strongly feels is unfair and onerous. The unwilling or the ‘untrained’ GP would be relegated to a lower level of a minion worker.

For some reason, there has always been that cynical belief by the health authorities that our GPs out there have been short-shrifting our patients thus far, that they have failed to deliver an appropriate level of care to our patients all these years. This, we believe, is unjustified and unlikely to be the general truth.

This has come across starkly in some of our dialogues with the Ministry of Health (MOH). Such is the mindset and perception of our health authorities! There is that prevalent feeling that GPs are not good enough and have done too little to improve the standards of their practice, although this has not been borne out by whatever little data that we have.

This is especially ironic when you consider that all our GPs have ‘graduated’ from the public system through at least 3 and now 4 years of compulsory service.

What does this imply for the apprenticeship role of the MOH, when the housemanship years are now extended into 2 years with mandatory rotations through various disciplines, and another 2 years of medical officership? Perhaps this speaks volumes for the disordered or ‘failed’ approach in ‘training’ or utilizing our MOs that they should still be considered inadequate after 5-6 years of medical school, 3-4 years of supervised housemanship and even mandatory medical officership!

I think this is grossly unfair to our doctors, that they should be perceived this way, unless there are inherent weaknesses in the system of training and supervision… Then the fault lies elsewhere, which must be corrected! I believe no other profession undergoes such a prolonged rigorous phase of supervision and still suffers the ignominy of being considered inept!

Even the lawyers have just one year of pupillage, post-CLP! We are not talking about rocket science here (even then the astrophysicist or engineer undergoes not more than 3-4 BSc, plus 4-5 years of PhD!), but basic general and yes, even family medicine practice!

But, it may be time for MOH to institute a more systematic training module for GP-wannabes; a more structured and perhaps senior GP-attachment for hands-on approach… This may be the preferred system than simply using the newly-minted medical officers as fresh pairs of hands to cover unwanted and unpopular disciplines, e.g. emergency departments, pathology, outpatients, administration, etc.

It is true that we have a dearth of information or research data pertaining to the performance or outcomes of our GPs. The MOH decries the fact that too few GPs participate in any surveys and studies to evaluate their services, their worth and outcomes. But this does not mean that our GPs are second-rated, as believed by the MOH.

Underperformance occurs in both public and private sectors

On the other hand, we have had at least 2 reports from the MOH describing just how poorly some of our public clinics have performed especially with respect to clinical and medication errors, etc. in particular those pertaining to non-doctor based services, i.e. those carried out by medical assistants or nurses.[7]

According to a Penang study, in 2009, “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.” [8]

To claim that several global health officials have expressed favourable opinions on our public health system, thereby implying that our government-run clinics are therefore excellent, is misleading and perhaps too self-congratulatory!

We readily accept that our infrastructure and system of primary healthcare access to most of our rural population within 5 kilometers is laudable, and has been adopted by other developing nations. But we beg to differ that these services provide the ‘best’ care that can be offered.

Consider the following mundane scenario of nearly every ‘public’ outpatient clinic, countrywide.

When it comes to chronic disease management, delivery of care is to say the least, sparse, sporadic and generally basic. There is very little continuity of care, with almost every clinic consultation (stretched to once in 4 to 6 months or longer!) being attended to by a different doctor nearly every time. Some 2 to 5 minutes seen in an overcrowded 2 to 3 patients in a shared space, cannot be the best approach—overworked medical officers furiously scribbling in self-kept medical cards, whatever little history, examination or tests, and in most instances, a rehash of the previous prescription (with little or no change), cannot truly imply good care or outcome!

Contrast this with the usual GP, who more often than not looks after families and perhaps even generations of families. The personal touch is all the more apparent in many cases, where chronic disease ailment such as hypertension, diabetes, arthritis and even some stable CVD are often looked after as best can be, with cost constraints being the usual bugbear. But GPs are adept at balancing costs with acceptable outcomes, and obviously do provide sufficient counseling to matter for the returning patient.

True, they also look after acute ailments such as fevers, cuts, falls, bruises, etc. Some even dabble in occupational health after undergoing some relevant courses. True too, that many a GP would prefer not to see the very ill or gravely injured patient due to lack of facility or support services. But such is the sagacity of good clinical practice to know one’s limits and refer judiciously.

The contention that many patients in the private sector doctor-hop and shop around is not the usual phenomenon, and probably occurs in a minority. But we do need more data to confirm or refute this and we urge our GP colleagues to participate in more studies to really address such possible misconceptions.

We also need to find out why many patients utilizing the public sector clinics revert to the GPs for either follow-up care, second opinions or reassuring care once in a while; or vice-versa—we need to document how well or how poorly some of these public-private shift of patients are doing and why.

We personally know of so ‘many’ instances of poor control of BP or blood glucose or HbA1c from government clinics that we must document the extent rather than just dwell in smirking hearsay. We urge GPs to document these carefully so that we can provide feedback of such suboptimal care to the authorities.

Similarly, the public clinics can and should also cross-document the mistakes or poor performances of the GPs or private sector out there. In the interests of patient safety, this should be the ongoing concern of every practicing physician, not to find fault but to monitor safety, so weaknesses can be identified and rectified. Until then, we believe that many of these are unfounded and based on inherent prejudices which apply both ways!

Market Forces & Private Sector Vibrancy

But perhaps the reality is simpler. MMA contends that the staggering 62% of the total Malaysian outpatient population, who rely on our GP services, cannot be an anomaly or a quirk of fate or circumstance!

Market forces, ease of care access, cost-effectiveness and reasonable outcomes, mean that most GPs must be doing something right. Of course there is information asymmetry, and that many patients may not know better, but we believe they are not stupid.

Of course, some patients do doctor-hop to find the best, most effective and most accommodating! After all, would anyone pay good money to have his/her illness badly treated, month on month? Would companies pay their panel doctors so that their employees’ health profiles deteriorate with time?

While insurance companies and third party payers complain bitterly about rising costs, would they continue to service such inept doctors if they are as bad as perceived?

Thus, we believe that the authorities have got their perceptions wrong, but we stand ready to be corrected.

The MOH must shift from their moral high ground and engage with the private sector, which play their critical part in alleviating the crush of needed services that the public sector cannot provide satisfactorily to the more discerning population. That despite their suspicion that market-driven health care is fraught with mercenary conflicts, this does not necessarily mean that the paying patients receive poor or sloppy care!

In most instances, the MMA believes that most patients (whether private or public) in Malaysia do receive a decent modicum of health care services, which are appropriate and cost-effective. But access can be improved particularly for the urban poor and the remote/rural needy.

Chronic disease management of course can be improved too, and our health indices must show better outcomes—the steady rise in non-communicable disease profiles is worrisome and may be reflective of public health malfunction due to faulty lifestyle excesses rather than therapeutic failures.

Catastrophic outcomes on the other hand can be better managed by both better promotive-preventive population-based measures, and yes, better concerted approaches to holistic chronic disease management. Of course, this implies that every doctor should actively engage in continuing professional development—we believe this is crucial for modern practice and professionalism.

We must find a middle path towards realising a more acceptable approach to reform our healthcare system, but we all need more data, research as well as greater stakeholder feedback and buy-in.

Misidentifying the private sector as a healthcare cost adversary would be off-target, and would only serve to deviate from the genuine problems associated with modern healthcare!

Also, by adhering to persistent and mistaken precepts, we may embark on a restructuring programme, which may meet with stout resistance and uncertain outcomes from both the medical profession and ultimately the more knowledgeable and empowered public.

---

[1] Robert H. Brook, MD PhD, Rand Corporation. What If Physicians Actually Had to Control Medical Costs? JAMA 2010: 304(13):1489-90

[2] Department of Health, UK. Equity and Excellence: Liberalising the NHS. London, DH, July 2010

[3] Dato’ Dr Maimunah bt A Hamid, Deputy Director General of Health (Research and Technical Support). 1Care for 1Malaysia:
Restructuring The Malaysian Health System. Presented at the 10^th Malaysia Health Plan Conference on 2^nd  February 2010

[4] Richard H. Brook, MD, PhD, Rand Corporation. Rights and Responsibilities in Health Care – Striking a Balance. JAMA 2010;303(22): 2289-90

[5] Ministry of Finance, Government of Malaysia. National Budget 2010

[6] World Health Report 2006 (Working Together for Health), Geneva, 2006

[7] Khoo EM, et al. Medical Errors in MOH Primary Care clinics. Research Highlight IPSK/H0/602/003/002(26)/2 of 2008/e2. Letter of intent for improving Patient Safety: Primary Care. MOH/S/IPSK/05.08(RR)

[8] Dr Jayabalan T and others, The Star, 07 January 2010, pg N45

The Star: DGH Ismail Merican: Ensuring access to healthcare

Ensuring access to healthcare
At Your Service by TAN SRI DR ISMAIL MERICAN
The Star, Saturday March 20, 2010

In responding to ‘Serving 1Malaysia’, especially towards ensuring equitable healthcare, the ministry has boldly moved towards initiating a major reform of the delivery of healthcare

The saying “health is wealth” holds true in every sense. Indeed, being the director-general of health, it is my responsibility to set the direction and course for the entire health system.

Having been both a healthcare professional and administrator, it has always been my priority to ensure equity (in health) by eliminating disparities in its provision. Our goal is for every individual to get the highest quality of care possible. Prudent investments in health are vital for national growth, human development and poverty reduction. The importance of a healthy population cannot be more strongly emphasised. It will improve the quality of life and increase productivity.

Equity in health implies that everyone should have a fair opportunity to attain his or her full health potential and that no one should be deprived of care when it is needed. In 2007, the London School of Economics reported that Malaysia’s public health sector has been relatively successful in providing equitable healthcare. To a large extent, access to healthcare is dependent on how healthcare is organised.

Historically, after Malaysia gained independence in 1957, the system was largely funded by the government. Patients only had to pay a nominal sum for access to outpatient and hospital admissions. In the 1980s, the service transformed from a system that depended heavily on the government to a dichotomous parallel system – the other player being the sizable and thriving private sector, for whom the Government has given strong encouragement for growth.

The private sector is, in fact, playing an ever-increasing role in the provision of healthcare for the country. However, as in most countries, the private sector, responding to market forces, has been concentrating its facilities in the more economically-developed regions. This contributes little to equity and social justice as such services mainly cater for patients who are able to afford them.

Nevertheless, the country’s health system has continued to perform relatively well over the years, despite the expanding dichotomy. The World Bank World Development Report published in 1993 stated that Malaysia was one of the countries where public health spending was biased towards the poor.

Truly, the government health services have benefited all. There is a strong consensus that subsidised public healthcare, if it continues to be properly tailored and targeted, can further the goal of promoting equity. Nevertheless, inequalities exist for many reasons such as distance, socio-demography, cost and transport problems. Therein lies the future challenges for our health system.

Based on current economic circumstances, the government is concerned about its ability to continue sustaining such levels of expenditure towards ensuring fairness in financing and the continued protection of the general population, and more so, the disadvantaged and vulnerable groups.

Demographic and epidemiological changes continue to alter demand for new healthcare services, whilst increasing affluence heightens expectations for care of even better quality. It is the primary objective of the government to have an efficient system that maximises well-being at the lowest cost to society.

The Health Ministry is in the process of examining reform options to ensure healthcare remains accessible, affordable and relevant. The role of the ministry must shift towards a stronger stewardship function – focusing on policy-making and enforcing regulations across both the public and private health sectors to ensure continued targets of equity, affordability and appropriateness of care are met.

In addition, the ministry will continue to set and monitor standards to ensure suitable quality of care. The fundamental step towards achieving better equity will be to strive for maintaining and enhancing universal access to healthcare. Although the concept of universal access has been well entrenched over the years, more needs to be done. This can be pursued by introducing a more structured and integrated health system, with greater participation of the private sector, underpinned by a comprehensive governance framework.

The plan for a big and bold transformation of the healthcare sector seeks to integrate both the public and private sectors, initially, in the provision of primary healthcare (PHC) services. This is a logical step since the majority of patient contacts occur at this level. If we are serious in our philosophy to provide healthcare based on the principles of needs, solidarity and equity, and in a cost-effective manner, it is prudent to pool resources. This is very much in line with the call of the Prime Minister towards serving 1Malaysia aspiration.

Focusing on PHC has received very strong support from the World Health Organisation. The latter calls for all member states to strengthen this strategy, as PHC can provide a stronger sense of direction and unity in the current context of fragmented health systems.

Specifically for Malaysia, strengthening the capacity and capability of the primary care physician and the multi-disciplinary team of allied health personnel will go a long way towards undertaking a “gatekeeper’s role”.

The overall effects of such a move on health are positive. Over-reliance on specialists and hospitalisation can be reduced by filtering out unnecessary uptake. As a result, the costs of hospital care can be reduced, the duration of hospitalisation shortened and the quality of post-hospitalisation follow-up improved.

The issue of equity is challenging but not insurmountable. Pressures are building for health reforms but these need to be managed in line with the development of a comprehensive strategy, tailor-made for the country.

In responding to “Serving 1Malaysia”, especially towards ensuring equitable healthcare, the ministry has boldly moved towards initiating a major reform of the delivery of healthcare. In this transformation, the ministry will develop and foster a system which is wide-ranging, in terms of scope and delivery, yet equitable, affordable, effective and efficient.

By laying a stronger foundation, involving greater collaboration with the private sector, the ministry will be able to pool scarce skilled resources and share high-tech equipment towards ensuring greater fairness in patient services. Given the right environment and political support, adhering to the principles of solidarity and social responsibility, and embracing the ethos “Rakyat didahulukan, Pencapaian diutamakan” will enable Malaysia to provide equitable and quality health services for all.

Tan Sri Dr Ismail Merican is the Health Director-General

Joint Meeting of AFPM, MMA, Qualitas & PCDOM on Primary Care Concerns

Joint Meeting of AFPM, MMA, Qualitas & PCDOM on Primary Care Concerns

Objectives:

To form a united working group which coordinates, collates and raises critical viewpoints of primary care medical practitioners, to provide timely responses to challenges and threats which may arise from time to time.

Members comprise of representatives from the various primary health care medical practitioner societies and groups, i.e. MMA, AFPM, PPSMMA, Qualitas, PCDOM, FPMFAM

Report on the Inaugural Working Group Meeting on 29.10.09, held at the Academy of Family Physicians of Malaysia Office, at Academy Building, Jalan Pahang

In attendance:

Dr. Frank Tan Eng Huat, AFPM

Dr. Sudha Nanthan, AFPM

Dr. Noor Azizah Tahir, AFPM

Dr. David Quek, MMA

Dato Dr. Tharmaseelan, MMA

Dato Dr. Mohan Singh, PPSMMA

Dato Dr. Noorul Ameen, Qualitas

Dr. Molly Cheah, PCDOM

The discussions covered many aspects of the impacts where the family medicine doctors / GPs are affected by new developments, such as:

1. MSQH trying to impose the credentialing and quality-assessment of GP clinics

-         Possibility of charging a fee for auditing our medical clinics

-         two weekly statistics returns that is imposed on the administration of the clinics

-         regulatory mechanisms that will further burden us

-         possibility of MSQH lobbying to regulate through new initiatives through the Cabinet or EPU, or through subtle imposition of standards requirements before GP clinics are afforded panel status or even eventual reimbursement schemes, health care insurance restructuring

-         enforcement surveys being carried out by paid surveyors/officers, perhaps similar to the processes of  Fomema, or Unit Amalan of KKM

-         We want to manage our own Quality Assurance.

-         Accreditation should be voluntary, and should not encumber or discriminate against those without such quality assessments.

2. Setting up of feeder clinics and primary care clinics by many tertiary Private Hospitals

3. MOH opening up more primary care clinics, such as 1Malaysia clinics manned by MAs

Our Aim: to discuss proactive methods to try and prevent these developments from taking place without safeguards and to lessen the impacts of such possible oversight processes from overwhelming our medical practices.

The minutes below detail the discussions of the group:

Opening Remarks

Dr. Frank Tan Eng Huat, President of AFPM called the meeting to order at 3.30 pm. In his opening address the President mentioned about the worrying trend where primary care centres were being opened by private hospitals, by Wellness Laboratories and even by the ministry of health.

He welcomed all present. Dr. Frank then requested the members to introduce themselves. The AFPM President then asked the members of the various groups to have an open discussion on the various issues highlighted.

Matters Discussed

MSQH Concerns

There were lively open discussions and debating by all the members. Dr. Sudha requested each member of the group to please look into the future with a new vision and as a  team. He said that there were some common grievances that we are facing now. Each of these must be addressed and brought up. The main issues were in the agenda. The new ones brought up today can be brought up later or at the next meeting.

Dr Sudha gave a run down  of the role of MSQH all these years and the role of MMA and MMA’s contribution of RM100,000. He said that the DG supported MSQH since 2007 but later came to know of the work done by the Academy through its subsidiary QIP. Subsequently, the DG has been supporting AFPM’s QIP and has advised that all primary care groups work together.

Dr Sudha said that he was directed by the Chairman of AFPM, Dato Thuraiappah to get the primary care groups together to have a meeting. Dr Sudha was further supported in this endeavour by Dr David Quek when he brought it up at the MMA Council meeting. That is how all the members are here today.

PPSMMA Perspective

Dato Dr Mohan then mentioned that he had the gathered various documents of the deals that MMA had made with MSQH. He said that the direction that the working partnership had taken was different now compared with what was envisioned. The threat of parliamentary support for MSQH would mean that further regulations would be imposed upon GPs and considering that hospitals were spending a fortune for the MSQH accreditation, the same could be imposed upon us.

Qualitas Input

Dato Noorul Ameen gave a description of the workings of MSQH and he said that they were already in the process of setting up a pilot project based on a good assessment tool. He said that AFPM was represented by the various members at MSQH before, but a strong enough voice was not heard from them.

Dato Noorul was against the idea of further regulations forced upon GPs.

He also said that he was disappointed with AFPM and MMA for their lack of appropriate actions when called upon to be more involved or vocal, in the past.

MMA’s perspectives

Dr David Quek then joined in, and commented on the lack of serious, concerted and quality participation by the GP sector. This was echoed by Dr Norazizah and also Dato Dr Tharma. He also said that GPs hardly attended GP meetings, MMA AGMs, other seminars like the H1N1 etc. Their participation in PPSMMA is also very selected and insufficient in numbers to give more impact.

Our GP groups also appear to be weak in coming forwards with detailed working papers or research which can help influence national health policy matters. He contrasted our weaknesses compared with that of the UK where the GPs’ strength is phenomenal and their input into the NHS enormous and substantive.

Declining GP remuneration

Dato Noorul, Dr Norazizah and Dr Molly Cheah then discussed on the declining and poor remunerations of the GPs and the cost of locums which especially of late, had gone up further because of MOH initiatives. Everybody then decided that one of the issues to be discussed at the next meeting would be stressing on need for a better and more reasonable GP remuneration.

The past actions and relatively passive responses by MMA and AFPM were discussed at length and eventually it was agreed that the new working group would in future work together, have regular meetings and be more pro-active in their stance.

PCDOM, Membership issues

Dr Molly Cheah came up with the role of PCDOM, its computer medical information systems, and the lack of participation by fellow colleagues.  This may be discussed at the next meeting.

Dr David Quek reminded Dr Cheah that membership numbers are also important for GP groups to impact on any important issues which are raised. He asked if PCDOM can share its membership numbers, so that whatever is raised by its leadership can then have greater weight and influence.

Dr Quek admitted that even the MMA has membership issues which are declining in proportion to the rising number of registered doctors in the country—we are now only about 32% of all the 25000+ registered doctors, but still the largest representative group for doctors.

Accreditation issues should not be regulated

Dato Noorul then suggested that we must first of all address the threat of the Accreditation of Primary Care being brought up to parliament which means that it could become an act and there fore another regulatory mechanism enforced upon the GPs. He suggested that we must first of all act upon that.

He said that following that, we can all work together, and suggested that with the MMA and Dr David taking the lead in tackling the various grievances, perhaps we can then implement the quality assurance programmes through the AFPM, we can bring in the rest of our working group to tackle the problems facing us.

Dato Mohan strongly supported and reinforced that the accreditation process should not be allowed to be tabled at parliament by MSQH.

Dato Dr Tharma then summarised the issues discussed

a. Press / Media campaigns  –  to stop further regulations that could be enforced upon us through mandatory  accreditation. Accreditation should be a voluntary process.

b. Identifying ourselves as a new working group that coordinates all the different challenges and threats that we face.

 c. Discussion on these issues should be an on-going process.

d. Primary Care Doctors should have a recognised GP group like the SCHOMOS to discuss the various issues faced by GPs. PPSMMA will encourage GPs to work with MMA in full force to help realise our objectives more effectively and collectively.

e. This working group will meet again next month. A Thursday at about 5.30 pm was suggested. The discussions will be based upon an agenda that will be drawn up.

f. As part of the agenda:

      - The Strengths/ Weaknesses of each component of our  working group will be outlined and addressed

    - A New Vision and objectives will be the thrust.

    - All GP groups and primary care doctors will be indentified.

    - All members of the working group were advised to contribute towards the agenda.

Other matters:

The next meeting by this group (name to be decided) would be hosted at the MMA House, The discussions will be based upon an agenda that will be drawn up. The course of  action on the various issues will be decided there.

Action Points

The members of the group were requested to give the ideas and comments on the various points to be discussed. Dr Quek asked Dr Norazizah to come up with some ideas to encourage GPs to take an active part in matters affecting them. He also requested Dato Dr Noorul Ameen to come up with a paper on costs comparing primary care managed by GPs to that managed by the government  and the effect  opening of primary care centres will have on the economy.

Meeting with DG Health

Dr Sudha then mentioned that the AFPM had set up a meeting with the DG of Health on the 4^th of November at 12 pm. He said that representatives from each group was ideal. Dato Mohan could come, Dr Norazizah will try and Dr Molly Cheah will come. Dr Noorul will send a representative. Academy will be represented by the EXCO.

The meeting adjourned at 5.30pm

Prepared by   :           Nalini Balakrisna

Date                :           30^th October 2009

                              

Checked by   :           Dr. Sudha Nanthan / Dr David Quek

Date                :           18^th Nov 2009