NST Letter: Healthcare services: Need to work together... by Dr Md Azmi Ahmad Hassali & Dr Jayabalan Thambyappa

Healthcare services: Need to work together

2011/03/16
ASSOCIATE PROFESSOR DR MOHAMED AZMI AHMAD HASSALI and DR JAYABALAN THAMBYAPPA, Discipline of Social and Administrative Pharmacy,School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang

letters@nst.com.my

OVER the last 10 years, national statistics on health have indicated a significant increase in the number of non-communicable diseases such as diabetes and cardiovascular-related diseases among the population.

The main reasons for this increase include the lack of awareness and lackadaisical attitude towards leading a healthy lifestyle.

It is also interesting to note that despite the numerous health campaigns and activities nationwide by the government or non-governmental organisations, the impact and outcomes of these programmes have been minimal in reducing the disease burden.

The time has come for healthcare providers to ask themselves: "What has gone wrong and who is to blame?"

The lack of interprofessional collaboration among partners in healthcare delivery in pushing health promotion agenda is to blame.

It cannot be denied that in the public sector, the government through the Health Ministry, has done a tremendous job in ensuring the delivery of preventive services via the provision of primary healthcare services.

However, one of the setbacks is that the current public demand has resulted in manpower and the cost of running such programmes stretched to the limits because of extreme focus on one group of healthcare professionals -- the medical doctors.

Therefore, it's time to engage a broader group of healthcare professionals in such an activity.

With the importance of primary care services emphasised by international health bodies such as the World Health Organisation, the current training of health professionals has also been transformed.

Subjects such as public health and epidemiology, which were traditionally taught only to medical students, have now been made compulsory subjects in all health professional undergraduate training.

For example, public health and epidemiology are core subjects in the curriculum of most pharmacy courses in the country. Similarly, public health subjects are also incorporated into the curriculum of nursing programmes and other allied health science courses.

In the private sector, primary healthcare providers, comprising general practitioners, dentists and pharmacists, are in the best position to take the health promotion agenda further.

Unfortunately, although it is mandated that health promotion activities are to be provided by primary healthcare workers, the uptake among practitioners is very low and interest in providing such intervention is minimal because of the non-profitable nature of such interventions.

The problem in our country is that nearly all relevant healthcare professionals in the private primary care services work with a silo mentality.

Primary care services can only be enhanced when there is coordinated effort. But most healthcare providers do not complement each other's roles and tend to put their interest in business first rather than patient care.

Feedback from colleagues in both the medical and pharmaceutical fraternity shows that most of them blame the existing out-of-pocket services as the main obstacle towards working in close collaboration with each other.

Consequently, business interests and survival in the healthcare market become top priority for healthcare providers.

In the long term, this is unhealthy as consumers are the ones who will be victimised.

One may argue that by having too many health professionals, our primary healthcare will become too expensive.

But this is unlikely as health promotion advice and counselling from community pharmacies for instance, are free of charge or at a very minimal cost.

Furthermore, community pharmacists are very well trained to deal with minor illnesses, which can be easily managed with over-the-counter preparations.

Besides, by forging interprofessional collaboration, pharmacists will refer their patients to general practitioners or other allied health personnel if the patients need further diagnosis or out-of-prescription treatment.

This has been successfully implemented in many developed nations and it is our belief that this model can be implemented here.

It is hoped that both professional bodies and individual practitioners can exchange ideas and discuss the creation of a model for successful interprofessional care.

Once a model has been created, it is crucial to study its effectiveness in preventive care. This is to ensure that there is sufficient evidence to institute policy changes for the benefit of society.

Read more: Healthcare services: Need to work together http://www.nst.com.my/nst/articles/20serva/Article/#ixzz1GmIbDeEc

1M Clinic: Advice and Comments from Senior Doctors

Further Advice and Comments from Senior Doctors

Dr Steven Chow, President, FPMPAM (MMA member):

I can empathise with you the difficulties navigating through the challenges leading our medical fraternity in today's scenario.

Clearly,Klinik 1Malaysia is just another nut and bolt of a bigger political agenda. It is a political response to the issue of medical provision disparity in the urban poor. Legally and morally, the government of the day has the mandate to do so. The current public perception is that it is wrong for the private medical profession to challenge this.

When the Klinik 1Malaysia program was first revealed on Budget Day 2009 it was a body blow to the private practitioners. On the one hand, the PHFSAct and Regulations clearly requires private clinics to be manned at all material time by a registered medical practitioner. On the other hand, these 1Malaysia clinics need only to be manned by HAs and MAs. We fully agree with you and our doctors on this point and have already written earlier to express our concern regarding this irregularity.

After the launch of the PHFSAct Regulations 2006, we met the then Minister of Health on 16.8.2006 with our set of proposed amendments to the Regulations. He was absolutely supportive and the following points were categorically stated:

1.    The said Regulations simply prescribes the basic minimum standards that private healthcare facilities must adhere to by law and that these standards were applicable to BOTH private and public healthcare facilities. This was the explicit comment of the Minister in the presence of his entire senior MOH officials.

2.    The objective of the Law was not to criminalise the private doctors or to jail anyone of them.

However, the Minister did add a caveat, ie: "as long as he was the Minister" etc etc. Well, time and history has told a different story. I am afraid, history may repeat itself again with your forthcoming meeting.

The unfortunate thing is that GPs have previously been prosecuted and clinics closed when they were found to have HAs or MAs covering for them. The basic principle is that there cannot be a different set of laws for the private and the public sectors.The way forward is to push for specific amendments in the  PHFSA Regulations to specifically state that likewise  private clinics can also engage HAs and MAs.

The notice is already out for a meeting to discuss the draft amendments to the PHFSA Regulations on 12.1.2010. We need to focus our efforts on this meeting.The promised amendments are already 3 years late.

The rice-bowl of the GPs is unlikely to be significantly affected by these 50 clinics. The patients they cater for are likely to be those who are going to the government hospitals OPDs anyway. The PR line of the MOH is politically correct ie.  the scope of their function and capability will be different to that of a private medical clinic and they are there to serve a unmet social need. We can see that as a strategy, these clinics are likely to be situated in areas where the urban poor have limited access and also affordability to private care.

In a bigger picture, the livelihood of the GPs will be severely affected by the following:

1.    Private hospitals opening chains of feeder clinics under the guise of wellness screening centre etc etc 

Surprisingly, the MOH have approved the registration of such feeder clinics. This is already happening and will escalate with the developing scenario where the major private hospitals are already under GLCs. .The present laws and regulations are silent with regards to the business dealings of these hospitals.Their justification is that some university hospitals are also providing such services.

2.    Foreign enterprises opening private healthcare facilities in Malaysia and or buying up  GP/ primary care clinics with the inception of AFTA and the MRA with effect from 1.1.2010.If Malaysian doctors are too expensive to employ they may jolly well import them from lower-cost neighbouring countries.

3.    Loss of the dispensing facility of private clinics - this is being actively pursued by the pharmacist lobby and it does appear that it has the MOH sanction.To our knowledge, there is stated policy in the MOH and a roadmap is already in existence for its implementation in less than 5 years time..

4.    Incursion into the traditional medical practice by industry like private laboratories, health screening enterprises etc. including operating and running of clinics.

5.    Discounts, administrative charges,management fees etc etc extracted by MCOs. TTPs, insurance companies and all sorts of medical middlemen.

6.    Profession Fee schedule not in synchrony with rising operational cost 

What is extremely worrisome is the future implications and evolution of the 1MClinic model. The way things are going, there is nothing to prevent some enterprising private healthcare companies with the backing of GLCs to capitalise on the 1MClinic model and develop this into a full blown industry. It makes good business sense.

The stage is now set for a perfect storm when all these players get their act together.

Sadly, soon we will see the demise of the existing independent private GP system of this country that has faithfully provided for 60% of the outpatient care at an affordable cost. We are already hearing of comments by some in the MOH clamouring for the "nationalisation" of the independent private GP system.. Aren't we all "One Malaysian doctors",we have asked  "What is there to nationalise further? Why are we not treasuring a system that has worked wonderfully well for our rakyat? Why do we allow commercial entities to suck away the money that the people have diligently put aside for their healthcare?

The bottom-line is that healthcare cost will sky-rocket, the public will complain, the doctors will be blamed and the government will enact more regulations and there will yet be another cycle of self-perpetuating change.

Best wishes for your meeting.

Datuk Dr DM Thuraiappah (Chairman, AFPM):

We think we should address a fundamental question.

1. The MOH should stop creating reactions from the profession on knee-jerk proposals from politicians.
2. I have heard from a MOH official that the MOH does have a blue-print of the national health reforms. However, if there is a blue print, then MMA should be consulted.
3. MMA should push for reform of the health care system by MOH divesting itself and bringing about the following:
1. MOH to be a policy maker and monitor of regulations.
2. Healthcare to be delivered by Primary, Secondary and Tertiary Care Trusts.
3. The National Health Fund to be the payor for the delivery of health care.

MMA can then deal with the three institutions as and when necessary for different needs. Good uniform healthcare delivery in the nation should be a common goal and we should not be competing with each other.

I think we should put this forward as our contribution to the nation.

Dato' Dr Joseph Eravelly (Past President Academy Medicine, Malaysia): 

I have been following the many comments from leading office bearers of the MMA past and present. I am glad that the general tone is one of common sense, moderation, and not a rush to rash action.

Dr. Mohan Das’ comments are rational and needs to be studied carefully.  So also is the paper sent by Dr. Steven Chow.  

I am afraid the President should not wait to be guided by the views of the majority. The majority view may sometimes become emotional and almost mob-like. Instead as a leader he must lead.  Any crisis is an opportunity to think strategically and come up with solutions that earn the respect of your members.

After reading the many comments I thought I will add my two cents worth to everything that has been expressed. 

I believe there are two issues to be addressed here. The first is not just an incident which has generated all this heat. That incident is but a part of the larger and emerging risks of private medicine especially for GPs. Steven Chow has described these risks in some detail but does not offer solutions. 

The second issue is what the MMA can do for its members.  It requires thinking rationally and planning ahead instead of reacting to every crisis as it occurs.

Let me take the first issue. It is a fact that every doctor that goes into private practice (specialist or GP) has one primary overriding objective. That is to earn a better income for himself and his family.  He moves into the free market. He must but usually does not, understand the principle of SWOT. His limitations are imposed by the way he practices as well as by competition and the price elasticity of supply and demand.  His patients are really customers who must perceive value in paying his charges. Nowadays that customer is getting smarter and realizes that there are choices.

Businesses plan according to perceived behavior of customers.  They also use marketing tools to influence customer behavior.  Sure costs go up but clever marketing can persuade people to bear higher costs.

The business environment that the doctor works in will, and does, change. The pace of this change will quicken. Now freely available are BP sets, glucometers, and self-requested complete lab tests. Soon abdominal ultrasounds, brain scans, and even CT angiograms on-demand may become available. Consumers will also increasingly buy medicines directly from pharmacies without prescriptions or get a prescription for a small fee without consulting a doctor.  There are other dangers that have been lucidly pointed out by Steven Chow.  

Why consumers have changed is because of economics – price, convenience and speed. There is also an increasing belief that there is little value in consulting GPs. This is perhaps also reinforced by the GP himself behaving like he is selling medicines.   This is why I think it is better to give up dispensing and charge for prescriptions. 

But change in business models associated with altered consumer behavior is also affecting other businesses.  Mobile phone companies, PC makers, automobile companies, airlines, and even retailers suffer in the face of this change. They spend millions trying to anticipate and adapt not only to new technology but changing regulations by the regulator. Some die and fade from the scene.   Why then should a medical business playing in the same market complain and ask for protection. 

All these businesses play by the rules of the free market. That market is remorseless and unforgiving but generally fair and favors efficiency.   In the case of medicine especially governments will intervene if there is a sense of market failure by which I mean a failure to allocate resources efficiently according to needs.  Think Obama and his healthcare plan in the USA. 

The trigger event for today’s discourse is the implementation of 1Malaysia Clinics. As Tan Sri Ismail has said, that should not affect GPs and I agree. What is being planned in Malaysia is also occurring in different ways in the world. Let me explain.

In the US for example, for many years now nurses have been trained as anesthesiologists, and give G.A. even for brain and heart surgery operations.  At the Mayo Clinic they are using nurse practitioners to stand in for doctors on night calls with the power to prescribe and to call for tests. Technicians do bone marrow biopsies almost as if on an assembly line. Nurses and technicians insert and manage ventricular assist balloon pumps and pass pressure lines and Swan-Ganz catheters when required. These providers are trained and certified. The point to note is that it is possible to use non-doctors to do relatively sophisticated medical procedures.   It is a fact of life we must anticipate and accept. 

Compared to all these things that paramedics are being better trained to do, the work of the GP in his clinic looks like a walk in the park. To oppose the 1Malaysia proposal by the government will be tantamount to saying that better educated, better trained doctors cannot compete with nurses and medical assistants in the free market.  This argument sounds absurd.  Hence opposition to this activity should stop.

I come to my next point.  What can the MMA do for its members?  I fear that the MMA has become gridlocked in a huge bureaucracy. Most of this mess is created by doctors themselves, not the leaders.  There is nothing that the MMA seems to do for the betterment of its members.  No wonder your membership declines. 

Yet MMA is a very important organization that must be protected and enhanced.  It calls for a paradigm shift in thinking.  I have raised a few points on this line of thinking in a letter to you in August 2009. There is no point repeating everything else that I said before. The most important point worth repeating is that the MMA has Market Power.   We must understand this and learn how to use it in the free market.  

My Comments (DQ):

Thanks for all the feedback and comments. As I have said so earlier, approaches to leadership differs from one to another. 

One can opt to be autocratic, consultative, or leading by consensual direction, based on personal conviction and majoritarianism. The latter is what I practise. I do not believe I have the sole right to simply push ahead with my own opinions alone, although I may have a broader perspective than most.


Most of the points raised have actually ben raised by me in my President's pages and past editorials. But they are certainly worth repeating for those not in the know.

Regarding Steven's points of GP challenges, most if not all were enumerated in my September MMA News President's page, where I addressed the many issues which we are helping to resolve. Yes we will be fully committed to be present at the Amendment exercise for the Private Health Care Facilities and Services Act which will be held next Tuesday, where I will lead our MMA team.

I agree with Joe Eravelly that the 1M clinics will make only a very small dent, if at all, on the urban GP's financial concern, which is what I had stated at the earliest statements. 

However, this nonconsultative manner in which such policy change of task-shifting had been announced and implemented, is disturbing, and may become a very critical slippery slope from which all other government-MOH-doctor relations might in future be defined. 

If projects or policies are deemed for the so-called 'public good' or worse, for political mileage, then any authority can and will go ahead, regardless. 

I believe doctors as a group should not stand by as toothless tigers. We have to make a stand to be counted, that is my position as defined in my election manifesto, and I will pursue this if supported by my members, without fear or favour. 

Just because something is a done deal and/or foregone conclusion, if it is wrong or unacceptable, does not make it an irreparable right. It should still be opposed and hopefully rectified or modified to an acceptable compromise. This way, we move forwards with our cross-purposes being assuaged in some small ways, evolving into what we call a win-win situation. 

We must not allow our status to be continually eroded so that we can be dismissively bypassed without being consulted. Indeed we must learn to imagine the bigger picture; imagine a master plan when the entire National Health structure becomes revamped overnight, then what? 

It is a frightening scenario. But thankfully, thus far we the MMA, have been consulted on the preliminary aspects of the possible revamp embedded in the 10th Malaysia Plan.

In this day and age and especially after March 8, 2008, the Malaysian people have found a new and exciting liberated voice of empowerment--to question, to dialogue, to be counted and to help input their concerns and voices, so that a burgeoning sense of people power can be instilled into a laggard behemoth of more-of-the-same government. 

But be rest assured, we will not simply scream and shout, we will work earnestly but energetically together as best we can, but we must be counted as partners, not as mere puppets...

Although, many physicians especially specialists appear to see the 'bigger picture's and are somewhat  dismissive of the 'molehill' plight of the GPs;  my grapevine from the ground has been thunderingly loud, agitated and disturbed! I hear you all, and that is why I feel compelled to empathise with the GPs more. 

Personally, I am not in the least impacted by this issue, as of now. But I foresee a possible erosion of our strength and professional interests, if politicians and bureaucrats continue to simply enact policy changes and laws or even administrative dictates at will, without proper consultation with as many stakeholders as possible. 

A letter to the editor in The Star today, addresses a similar concern, while pointing out the shortcomings of our MA/nurses-led clinics even at our klinik kesihatans, already  so entrenched and in existence in the country. 

I believe we do have legitimate concerns, which must be resolved to the best possible compromise, with promises for greater consultation in the future. I think we are not asking too much, after all we are in this together, strange bed-fellows and all...

1M Clinics: Some More Comments from MMA members urging caution

1M Clinics: Some More Comments from MMA members urging caution, unfortunately mostly government servants, GPs must speak out, or your voices will not be heard...

Dr Krishna Kumar (NS):

dear all

 

I think you should clearly heed what datuk Mohandas has said

He is VERY CORRECT

do not shoot yourself in the foot

 

one of the main reasons for these clinic has been to address the urban poor who have been neglected for some time. as hospitals become specialised and sub-specialised, the A & E being streamlined to only address the emergency problems, minor ailments need to be channeled somewhere. it is therefore being used as achannel to divert the overload from the hospitals

 

Please note that these clinics are a big hit with the general public who cannot afford to go to the provate and do  not want to wait for long queues by the colour coding systems in the A & E depts of hospitals

 

there are a lot of doctors being produced annually as an excuse does not hold water. there will then be an arguement of the experience and training of these doctors. any mistakes by any doctors will then be further highlighted and will not receive any pity from the general public

 

My advise is to be very carful in addressing this issue and not appear to be looking at doctors' pockets only
 

krishna

My Comments: (DQ)

We hear you, but does anyone hear the GPs?

Being in govt service has comfort zones which unfortunately many in the private sector do not have the luxury of enjoying.

But of course we will be careful. But the MOH and the govt must understand that policy changes no matter how 'noble' the intentions, have implications. The medical profession must maintain our relevance in being important partners to dialogue with the authorities.

Our Private Healthcare Facilities and services Act also came about from noble intentions, but look how much it has impacted so many GPs and those in the private sector? We need to be powerful shapers of our own destiny, not simply reactors to insensitive dictates of policy makers and possible political ploys.

I will try balance what is two glaringly opposite and increasingly divergent clusters of viewpoints.

My only concern is that ultimately, we the doctors will be the that professional who might be facing greater and greater constraints and possible too much oversight, initially within the private sector, but soon when the overcrowded public sector cannot sustain all the newer graduates, then what?

I have always posited that the public must be our first concern, and that there must be better mechanisms to help everyone have universal access to health care. But being a student of medical interests and issues over the past 15 years, I am also in the position to recognise mounting challenges for the 'doctor' whose professionalism, livelihood and even modes of practice will evolve into something quite alien to what is currently experienced.

It is nice to sound so altruistic, but do look into the future, most of the MOs will likely be exploring the private domain, but in what capacity... Just my musings...

For many who are interested, please read the WMA's resolution just passed at the General Assembly after huge debate, end of last year.

Here's the WMA resolution that was adopted in the last General Assembly, which discusses the nuances and implications of Task shifting, and underscores what the medical profession is facing... WMA also cautions on the safety and quality of care. Even the increased nurse practitioners program is an eroding force for the future of doctors...

May be like dinosaurs, the medical profession will evolve into a toothless beasts of burden, worker ants/bees?

Knowledge of what has been happening around the world regarding the medical profession will help place some balance and focus on the possible future for us doctors...

WMA Resolution on Task Shifting from the Medical Profession

Patient Safety and Quality of Care Should be Paramount When Task Shifting

WMA: Patient Safety and Quality of Care Should be Paramount When Task Shifting

Patient Safety and Quality of Care Should be Paramount When Task Shifting

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(19.10.2009) A clear message to governments to give patient safety and quality of care the highest priority when considering task shifting in the delivery of health services has come from the World Medical Association.


In a new policy document approved at the its annual General Assembly in New Delhi, India, the WMA expressed a series of concerns about the global development of task shifting - where a task normally performed by a physician is transferred to a health worker less well qualified.

Chief among the significant risks was the possibility of the quality of patient care being compromised, particularly if medical judgment and decision making was transferred. Although the WMA accepted that in certain situations task shifting might improve quality care, there could in other situations be risks of reduced patient-physician contact, fragmented and inefficient service, lack of proper follow up, incorrect diagnosis and treatment and inability to deal with complications.

The Association warned that task shifting should not be undertaken or viewed solely as a cost saving measure and should not replace the development of sustainable, fully functioning health care systems.

It should be seen as only one response to the shortage of health workers and where it was implemented it should be seen only as an interim measure.

Assistive workers should not be employed at the expense of unemployed and underemployed health care professionals and task shifting should not replace the education and training of physicians and other health care professionals.

The resolution adopted by the WMA Assembly said that task shifting was often being initiated by health authorities, without consultation with physicians and their professional representative associations, and that consultation should always take place.

Dr. Edward Hill, Chair of the WMA, said:
‘We recognise the relevance of task shifting in countries where the alternative is no care at all. But the solution for one country cannot automatically be adopted by other countries.

‘And wherever this occurs it is important that tasks that should be performed only by physicians are well defined, including the role of diagnosis and prescribing. There must be a clear understanding of what each person is trained for and capable of doing, clear understanding of responsibilities and a defined, uniformly accepted use of terminology.’

WMA Resolution on Task Shifting from the Medical Profession

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Adopted by the WMA General Assembly, New Delhi, India, October 2009


In health care, the term "Task Shifting" is used to describe a situation where a task normally performed by a physician is transferred to a health professional with a different or lower level of education and training, or to a person specifically trained to perform a limited task only, without having a formal health education. Task shifting occurs both in countries facing shortages of physicians and those not facing shortages.

A major factor leading to task shifting is the shortage of qualified workers resulting from migration or other factors. In countries facing a critical shortage of physicians, task shifting may be used to train alternate health care workers or laypersons to perform tasks generally considered to be within the purview of the medical profession. 

The rationale behind the transferring of these tasks is that the alternative would be no service to those in need.  In such countries, task shifting is aimed at improving the health of extremely vulnerable populations, mostly to address current shortages of healthcare professionals or tackle specific health issues such as HIV.

In countries with the most extreme shortage of physicians, new cadres of health care workers have been established. However, those persons taking over physicians' tasks lack the broad education and training of physicians and must perform their tasks according to protocols, but without the knowledge, experience and professional judgement required to make proper decisions when complications arise or other deviations occur.

This may be appropriate in countries where the alternative to task shifting is no care at all but should not be extended to countries with different circumstances.

In countries not facing a critical shortage of physicians, task shifting may occur for various reasons: social, economic, and professional, sometimes under the guise of efficiency, savings or other unproven claims.  

It may be spurred, or, conversely, impeded, by professions seeking to expand or protect their traditional domain. 

It may be initiated by health authorities, by alternate health care workers and sometimes by physicians themselves. 

It may be facilitated by the advancement of medical technology, which standardizes the performance and interpretation of certain tasks, therefore allowing them to be performed by non-physicians or technical assistants instead of physicians.

This has typically been done in close collaboration with the medical profession. However, it must be recognized that medicine can never be viewed solely as a technical discipline.

Task shifting may occur within an already existing medical team, resulting in a reshuffling of the roles and functions performed by the members of such a team. It may also create new types of personnel whose function is to assist other health professionals, specifically physicians, as well as personnel trained to independently perform specific tasks.

Although task shifting may be useful in certain situations, and may sometimes improve the level of patient care, it carries with it significant risks. First and foremost among these is the risk of decreased quality of patient care, particularly if medical judgment and decision making is transferred. 

In addition to the fact that the patient may be cared for by a lesser trained health care worker, there are specific quality issues involved, including reduced patient-physician contact, fragmented and inefficient service, lack of proper follow up, incorrect diagnosis and treatment and inability to deal with complications.

In addition, task shifting which deploys assistive personnel may actually increase the demand on physicians. Physicians will have increasing responsibilities as trainers and supervisors, diverting scarce time from their many other tasks such as direct patient care. They may also have increased professional and/or legal responsibility for the care given by health care workers under their supervision.

The World Medical Association expresses particular apprehension over the fact that task shifting is often initiated by health authorities, without consultation with physicians and their professional representative associations.

RECOMMENDATIONS

Therefore, the World Medical Association recommends the following guidelines:

1. Quality and continuity of care and patient safety must never be compromised and should be the basis for all reforms and legislation dealing with task shifting.

2. When tasks are shifted away from physicians, physicians and their professional representative associations should be consulted and closely involved from the beginning in all aspects concerning the implementation of task shifting, especially in the reform of legislations and regulations. Physicians might themselves consider initiating and training a new cadre of assistants under their supervision and in accordance with principles of safety and proper patient care.

3. Quality assurance standards and treatment protocols must be defined, developed and supervised by physicians. Credentialing systems should be devised and implemented alongside the implementation of task shifting in order to ensure quality of care. Tasks that should be performed only by physicians must be clearly defined.  Specifically, the role of diagnosis and prescribing should be carefully studied.

4. In countries with a critical shortage of physicians, task shifting should be viewed as an interim strategy with a clearly formulated exit strategy. However, where conditions in a specific country make it likely that it will be implemented for the longer term, a strategy of sustainability must be implemented.

5. Task shifting should not replace the development of sustainable, fully functioning health care systems.  Assistive workers should not be employed at the expense of unemployed and underemployed health care professionals. Task shifting also should not replace the education and training of physicians and other health care professionals. The aspiration should be to train and employ more skilled workers rather than shifting tasks to less skilled workers.

6. Task shifting should not be undertaken or viewed solely as a cost saving measure as the economic benefits of task shifting remain unsubstantiated and because cost driven measures are unlikely to produce quality results in the best interest of patients. Credible analysis of the economic benefits of task shifting should be conducted in order to measure health outcomes, cost effectiveness and productivity.

7. Task shifting should be complemented with incentives for the retention of health professionals such as an increase of health professionals' salaries and improvement of working conditions.

8. The reasons underlying the need for task shifting differ from country to country and therefore solutions appropriate for one country cannot be automatically adopted by others.

9. The effect of task shifting on the overall functioning of health systems remains unclear. Assessments should be made of the impact of task shifting on patient and health outcomes as well as on efficiency and effectiveness of health care delivery.   In particular, when task shifting occurs in response to specific health issues, such as HIV, regular assessment and monitoring should be conducted of the entire health system. Such work is essential in order to ensure that these programs are improving the health of patients.

10. Task shifting must be studied and assessed independently and not under the auspices of those designated to perform or finance task shifting measures.

11. Task shifting is only one response to the health workforce shortage. Other methods, such as collaborative practice or a team/partner approach, should be developed in parallel and viewed as the gold standard. Task shifting should not replace the development of mutually supportive, interactive health care teams, coordinated by a physician, where each member can make his or her unique contribution to the care being provided.

12. In order for collaborative practice to succeed, training in leadership and teamwork must be improved.  There must also be a clear understanding of what each person is trained for and capable of doing, clear understanding of responsibilities and a defined, uniformly accepted use of terminology. 

13. Task shifting should be preceded by a systematic review, analysis and discussion of the potential needs, costs and benefits.   It should not be instituted solely as a reaction to other developments in the health care system.

14. Research must be conducted in order to identify successful training models.  Work will need to be aligned to various models currently in existence.  Research should also focus on the collection and sharing of information, evidence and outcomes.  Research and analysis must be comprehensive and physicians must be part of the process.

15. When appropriate, National Medical Associations should collaborate with associations of other health care professionals in setting the framework for task shifting.  The WMA shall consider establishing a framework for the sharing of information on this topic where members can discuss developments in their countries and their effects on patient care and outcomes.

MMA’s Grave Concern about 1Malaysia Clinics being manned by Medical Assistants

MMA’s Grave Concern about 1Malaysia Clinics being manned by Medical Assistants/Nurses

When Prime Minister Najib Razak announced in the Budget 2010, the setting up of 50 1Malaysia clinics in urban areas, the MMA was dumbfounded and perplexed.

That these clinics be set up at all, is perhaps a good exercise in public relations for our Prime Minister, who must have genuinely felt the need to offer some much needed goodwill to the urban folks, especially the poor and the marginalised.

However, what is more disturbing is the plan to have these clinics run by medical assistants and/or nurses, which in effect places the standard of these clinics at the level of third world countries, where there is a real scarcity of fully-registered physicians. It is certainly a major step backwards for a progressive nation such as Malaysia, which aspires to be fully developed by 2020, just 10 years away.

The Malaysian Medical Association (MMA) is gravely concerned that such a major shift in policy with regards public sector healthcare should be so implemented without sufficient input and discourse with stakeholders, such as the medical practitioners and perhaps even with officials of the Ministry of Health. It has been suggested that some health officials were also taken aback by this announcement, but they have been made to implement this as a directive, come January 2010. (I stand to be corrected on this fact.) It appears that this plan was brought about by fiat, rather than by persuasive rationale or long-term planning.

Firstly, let us reassure the public that the MMA is not simply protecting its turf. Of course, we are keenly interested in the welfare and wellbeing of medical practitioners, but we are also always concerned about our patients, i.e. the rakyat out there, who are our reason to exist, our raison d’être.

We welcome the government’s concern about our rakyat’s health needs. We also recognize that for many urban poor, their only recourse to health care is that offered by the overcrowded and understaffed MOH outpatient clinics. That there have been much queuing and long waiting times is notorious and wasteful in terms of productivity. Certainly we should do better.

We also know that new health ministry directives have been employed to try to shorten waiting times to less than 30 minutes; this has been included as part of the KPI/KRA so proudly announced by the government. Perhaps because of this huge problem, the need to lessen the burden of fixed outpatient clinics and the logistics of manpower distribution has prompted this new approach.

But we also urge the government to recognize that throughout the country, in urban areas, there are already in place many GP clinics, some only a few doors away from each other in almost every urban block of shop-houses or complexes.

There is a severe glut of GPs in urban areas, where in the Klang Valley, Penang, Johor Bahru, Melaka, Ipoh and other major towns. In all these townships and cities, the ratio of doctor to population is around 1 in 400, more than the WHO recommendation of 1 in 600.

While some GPs have been very successful, the great majority is simply ekeing out a meagre and mediocre living, many GPs are seeing less than 20 patients per day and so are under-utilised. This is grossly unproductive and wasteful when seen in the context of the long arduous training and huge expense required for producing any one doctor, whether locally or abroad.

Our problem is learning how to manage the distribution of the doctor-patient function better and more efficiently. It is with this in mind that for several years now, the MMA and the Ministry of Health have been seeking a better public-private partnership in shaping a better health care system for the country.

Unfortunately because of the differential system of fee and/or payment mechanisms, this is proving rather tricky to bring about a cohesive transferable system. Thus, there has even been growing talks about integrating the public-private sector for primary care medical services. This will hopefully seamlessly integrate the use of almost all GPs into a primary care network where the public can register and seek treatment at either public or GP clinics, interchangeably or by choice, with a common reimbursement mechanism. This will undoubtedly be the way forward.

Of course quite a few discrepancies need to be addressed, e.g. differing expectations, possibly standards of every aspect of care, variable amenities available, level of support staff, etc. But these can be worked out, and we are establishing common areas of standardisation, which will then ensure that the public can be assured of and experience as high a standard of health care as possible.

So, in this context, the hurried establishment of the new 1Malaysia Clinics appear irrational and un-called for. If the government feels genuinely that these have to be carried out regardless of the medical profession protestations, then the minimum that it should do, is to ensure that these clinics are duly manned by registered medical doctors, fully in charge of all aspects of the clinics. This standard of medical care should not be compromised.

Why is this such a prerogative? Because in this day and age, it is quite unbecoming to offer a lesser level of care to those citizens just because they cannot afford to pay to see a doctor. Employing medical assistants and nurses to do a doctor’s job is called task-shifting, which is employed mainly in third world countries where there is severe shortage of doctors. To do so in this country would be a major step backwards and in our MMA’s view, shameful and unnecessary.

Do we have enough doctors? Of course we do. It is just the mal-distribution and poor logistics, which need to be addressed. Recently, more than 2,500 new doctors joined the public service as house officers. It is understood that many of these are under-deployed in the various departments of the government hospitals.

Due to the mushrooming of so many medical schools (23 as of this year) in the country, and medical graduates returning from abroad, we will continue to have some 2,000 to 3,000 new doctors returning to our shores annually!

We can certainly tap into this growing number of doctors to help make our public service clinics more efficient. At the very least the public will be better served by some recognized registered medical doctor, although they may just have probationary medical licence—the fact remains that they have had sufficient training and learning. Medical officers, registrars and specialist, (who can also be deployed to enrich the public sector healthcare service, if need be), can supervise these younger doctors.

Why is the MMA so concerned about clinics being manned by medical assistants or other unregistered medical practitioner? Because under the Medical Act, this is illegal.

Because as of now and in the past, doctors who employ such unregistered persons have been charged and penalized for unprofessional conduct, with some severely sanctioned, even suspended or deregistered!

Because medical assistants cannot prescribe any more than some very simple medicines, cannot sign any medical leave chits or write any report, and would become subject to medico-legal challenges, with no precedents.

Because we are concerned that ‘bogus doctors’ should not be allowed to harm our rakyat! In the past there have been some bogus personnel who have continued to defraud many patients because many of them do not know the limits of their level of competence and training—who feel that they are not bound by any laws.

There should not be one law for some and another for others, even if approved by the government or the MOH.

Two wrongs do not make a right.

The MMA believes that setting up 1Malaysia Clinics in urban locales is wasteful, redundant and shortchanging the rakyat. Utilising the already many GP clinics would be the better way forward. 

Furthermore, manning these clinics by other than registered medical doctors is also wrong and undermines the health care service, which leads to a possibly poorer standard of care, which can lead to many uncharted medico-legal problems.

We urge a rethink about this project, and for the MOH to seriously look into the implications of this poorly advised move.

The MMA will strive to work together earnestly with the MOH to help raise the level of healthcare for Malaysians, but not by compromising on the standard of care, or of shortchanging the uninformed rakyat.

Dr David KL Quek, President MMA

1 Malaysia Clinics: More for the Haves?

1 Malaysia Clinics: More for the Haves?

Dato’ Dr Sarjeet Singh Sidhu

Hon. Dep Secretary, MMA

No sooner had the PM announced the 1 Malaysia Clinics to be set up in urban areas the idea was being lauded by one and (almost) all. 

On the surface it does seem to be a good idea. I mean who can quarrel with the idea that now more (Govt) clinics will be within striking distance for the urban folk in our over-extended, sprawling cities? 

No more long distance travels and no more long waits and the poorer sections of the rakyat can get the same treatment as their better-off counterparts who will be visiting the private clinics to avoid long waits at the Govt hospitals. That in essence, I think, is how most people will understand the concept. But no, some people have a different, if flawed understanding.

With the concept of 1Malaysia still quite nebulous in most citizens’ minds it is inevitable there be some confusion. The 1Malaysia concept is understood by some to be a vision wherein we (Malaysians) will think along non-ethnic lines, and by some to mean there will be a cross-section of ethnicities represented in every (Govt) department and in every phase of the nations development, that all Malaysians will have equal access to Govt funds (scholarships for example).

In general (hopefully) most Malaysians think it means or must mean “1 Malaysia policy should serve all and equitably” [1] or as some voices on one forum [2] said: “1Malaysia to me is Malaysia for Malaysians... 1 Country regardless of race” or “1Malaysia... A country of equal opportunities...  And ethnocentrism is a thing of the past.”

Whatever each individual’s perception of the concept the PM says that “the 1Malaysia concept’s ultimate objective is to achieve national unity among its people. He said "In other words, 1Malaysia is a concept to foster unity in Malaysians of all races based on several important values which should become the practice of every Malaysian””. [3]

Here is one more Malaysian who does not quite know what it all means; he asks: “Can someone enlighten me why there are plans to have "1Malaysia Clinic"? Do you mean that the clinic have Malay, Chinese, Indian and other doctors operating in? Do you mean that other clinics are not par with 1Malaysia theme? where clinics are not open for all? Do you think this "1Malaysia" tagline is over-used?” [4]

So now that we are sure that many Malaysians are unsure as to what 1Malaysia means perhaps we can take a look at the shortcomings in relation to the 1Malaysia clinics.

The World Medical Association (WMA) and the United Nations encourage “Task-Shifting” (TS) in specific situations. The WMA Resolution on TS [5], adopted by the WMA General Assembly, New Delhi, India, October 2009 describes it TS as “a situation where a task normally performed by a physician is transferred to a health professional with a different or lower level of education and training, or to a person specifically trained to perform a limited task only, without having a formal health education” (my emphasis). It further states “A major factor leading to task shifting is the shortage of qualified workers... The rationale behind the transferring of these tasks is that the alternative would be no service to those in need” (again emphasis added). The WMA does, however, caution that “This may be appropriate in countries where the alternative to task shifting is no care at all but should not be extended to countries with different circumstances”; in other words TS is not for places where there is already available quality healthcare provided by doctors.

Clearly, in our situation where the stated reason for opening these 1M clinics is “to ease the burden of government hospitals as there would be more patients seeking treatments for minor illnesses in these clinics” [6] the care will be provided by less skilled personnel (“manned by medical assistants or paramedics”). It would be difficult to oppose the plan if the 1M clinics were actually manned by doctors, but that is not the case here.

To my mind the obvious flaws in the IM clinics plan are:

1. These will provide service by less qualified personnel to that segment of Malaysians.
2. Not withstanding the above, these clinics will provide additional services to those who already possess such services by qualified personnel.
3. What is the standard of care that the courts will expect from these 1M clinics? If a lower standard is expected (i.e. commensurate with the training and expertise of the MAs) then this is clearly a case of providing lower standard of care in areas (urban) where a better standard of care is already established via the plethora of GP clinics in urban areas.
4. What will be the legal liabilities arising out of medical mishaps consequent upon the use of “medical assistants or paramedics”? And mishaps will arise sooner or later.

As Dr Mary Cardoza pointed out in an email correspondence “the concept of "bringing the service to the people" is good but there are already many GP clinics in the towns (to) provide this service to people.  The obvious areas where these IM clinics will be of better use are areas where NO service at all is available for now. Examples that spring to mind are the Orang Asli settlements (especially if far from towns), and the deep interiors of Sabah and Sarawak.

Every year Malaysia is set to get 3000 new doctors entering service (half from local universities and half from overseas universities). Already we have insufficient places for their housemanship training; many will be quickly released and enter private practice. How are all the current GPs and the new ones expected to come in going to make ends meet?

According to a Bernama report Penang is already looking at sites for these clinics [7] and this despite the knowledge that Penang already has so many GPs and Private hospitals in such a small area. This is again a case of providing even more benefits (IF there is any benefit to be derived from treatment by less qualified personnel) to those who already have more than ample access to healthcare whilst leaving out those who have NO access to healthcare.

It’s been reported that “For a start… an allocation of RM10 million will be provided to set up 50 clinics in selected areas” [6]. That works out to RM 200,000 per clinic per year. Now if the REAL aim of the 1M Clinics is “to ease the burden of government hospitals as there would be more patients seeking treatments for minor illnesses in these clinics” [6] then it will be far more prudent and convenient to spend that money by roping in the GPs who already dot the entire landscape of most cities and towns. Again as Dr Mary Cardoza points out in her mail “MMA has offered the services of its members for this purpose many years ago and was told that this was accepted in principle; however, nothing concrete has materialised”.

I, for one, cannot fathom how 10 clinics, strategically located in overpopulated areas of our cities, with ample quality care available can be a move forward because they will now have even more clinics, run by less qualified personnel, to make life easier for them, whilst large areas with no or inadequate healthcare will remain so for some time more? 

Is it because these areas are under-populated? 

Am I missing something: more for the ‘haves’ and less for the ‘have-nots’?

References:

1. http://dayakbaru.com/weblog08/2009/04/27/re-thinking-one-malaysia-concept/
2. http://recom.org/forum/showthread.php?t=9129
3. http://www.malaysiatoday.com/Latest-News/1malaysia-concept-all-about-unity-pm.html
4. http://blog.thestar.com.my/permalink.asp?id=27428
5. http://www.wma.net/en/30publications/10policies/t4/index.html

6. NST 23 Oct 2009 http://www.nst.com.my/articles/20091023203300/Article/index_html
7. http://malaysia.news.yahoo.com/bnm/20091024/tts-nor-land-bm-993ba14.html

15 November 2009

Post-Script:

After I wrote of the above it was brought to my notice by a politically well-connected individual that there is more to the 1M clinics than meets the eye. It seems that the push for such clinics came from the Medical Assistants (MA), once called Hospital assistants (HA), and recently “promoted” to Assistant Medical Officers (AMO). Evidently the suggestion for such clinics, to be run by the MAs/HAs/ AMOs, came from the MAs themselves. It’s been said that this is one way for some of them to remain in the urban areas (mainly the cities and larger townships) and not get posted out to remote areas. The designation as AMOs gives them better status and, together with the running of the 1M clinics, will add weight to their requests for a jump to a higher level on the pay scale. But why would anyone pay attention to such requests? Well, it’s been said that are many of these MAs, and a great number of them are active (influential?) party members. Makes sense? It does if the story is true.

MMA: Treading between Advocacy & Professional Balance

MMA: Treading between Advocacy & Professional Balance

President's Page, MMA News, October 2009

“There is no career nobler than that of the physician.  The progress and welfare of society is more intimately bound up with the prevailing tone and influence of the medical profession than with the status of any other class...” ~ Elizabeth Blackwell, M.D., 1889

Medical Professionalism and our Caring Vocation

As medical professionals, our patients should be our raison d’être, our sine qua non for existing.

However, as is becoming more evident, daily societal developments pose severe challenges to our medical profession. Our role as physicians sometimes appears to come into conflict or competition with society’s other demands—some social, while others, political.

Yet, we must choose a careful path, treading a thin line between strident but necessary advocacy and rational professional balance on the other. Above all, we must remain steadfast as our patients’ strongest advocate—their health interests must precede all others. 

During the start of my term of office, I had highlighted that I would emphasise the more humane aspects of the medical professional, that kindlier face of the doctor as we interact daily with our patients. As physicians, we must strive to always practice our craft without that edgy touch of cynicism, jadedness and/or burnout.

We must project that long-forgotten intimate encounter which makes us the most trusted and respected amongst professionals. We must re-ignite that fervour to make this a daily reality for our patients and all those whom we connect with through all walks of life.

But this must be through one’s personal conscious effort—it does not come naturally to most of us… The good thing is that we can learn and adapt until this becomes a part of our attitude, our persona.

My personal daily goal is to see if I could get each and every one of my patients to leave my consultation room with a contented smile; yes, despite the fees, the test results and burden of illness. The hospitalized patient poses a rather more difficult problem—many are too ill or too discomfited to be satisfied, but he or she can usually be consoled, especially when we show that we care. And most patients can actually sense our sincerity and our empathy.

But this is by no means a given. We all have our off-days, days when we are troubled by our own unresolved nagging tribulations and private burdens. Just to shake off these deep-rooted weights would make most of us sullen, poorly communicative people, who would not normally be expected to make good counsellors or empathetic muses!

Yet, that is expected of us, to perform even in the midst of personal distress and overbearing internal conflicts. I have striven to do this for some years now, but sometimes this just isn’t possible. Undoubtedly, this will increase our stress level which is now recognized even by our own citizens! In a recent poll, Malaysians had voted doctors as the second most stressful job among the professions, the PM's position being the one to beat!

How do we inform seriously ill patients that their ailment is life threatening, or even terminal? How do we get the patients and their loved ones to come to grips with the dire prognoses, the possible huge treatment costs, and the uncertain outcomes for some illness? How do we sometimes admit our limitations that even we do not have all the answers?

Yet on the more mundane aspects, how do we continue to inculcate a sense of shared intervention and commitment to some therapeutic regimen for some chronic ailments such as hypertension, diabetes, etc.? We need to constantly urge even ‘gently berate’ our patients to stay on treatment for the best outcomes in the long term, especially when the symptoms are covert, apparently nonexistent, or even silent?

As doctors, we must regularly remind ourselves that among the professions, we are perhaps the only one that demands a caring value system. We must constantly remind ourselves of this duty.

Yet again there are other issues, which demand our action and our input, at least this is what I have pledged to do. There are problems with some of our health care services such as our forensic service, which has been under the spotlight recently.

Careless and callous attention to detail has created great public uncertainty, dismay and disbelief, which undermines the critical function of our forensic pathology services. The MMA naturally would stress that forensic health care is every bit as essential for the final truth and professional determination of causation of death or injury, especially of anyone under detention—as is demanded of us the medical professional, in WMA’s Declarations of Tokyo and Istanbul.

 

Let us practice the noble art of medicine as has been enjoined upon us from time immemorial.  Let us engage more meaningfully and help shape the kind of medical practice that we would all be proud of. 

Ongoing Challenges

Just 4 months into the fiscal year, and the MMA continues to face new or resurgent challenges. Some of these are simply perennial issues, which surface periodically when political awakenings rekindle them into topical issues of importance of the day. Others are the result of unforeseen or poorly planned policies that have now come home to roost with outcomes that seriously impact our profession and our practice.

1. Competition is becoming more intense than ever. We continue to have complaints of community pharmacies posing as clinics, providing discounted medicines to unsuspecting patients who have elected to purchase their medications without prescription. This continues to take place, despite MMA’s consistently vocal stance that safety issues and laws have been breached.

We also have the understanding from the Malaysian Pharmaceutical Society that it is trying hard to rein in their pharmacies, their members. But the MPS has also repeatedly called for a greater if total separation of duties—to let each professional earn his/her true value and worth.  The MPS continues to urge that perhaps doctors can start by being a little more transparent in their prescribing and dispensing habits. We are trying to resolve some common interests through greater dialogue, which may benefit both parties as a win-win approach—but we are a long way off a final agreement or compromise.

In most urban centres, there is a glut of side-by-side clinics, thereby causing intense competition for patients both from self-paying patients as well as for panel contracts or even third party payer MCOs, which are demanding depressingly low capitation fees for services.

Latterly, there were reports of some private medical centres/hospitals expanding their coverage with feeder clinics and wellness centres. Undoubtedly, these are patently to recruit more patients for their services, their laboratories and their hospital facilities. 

We have recently sent notice of our displeasure to the press, and urge the authorities to nip these practices in the bud!

 

2. ‘1Malaysia Clinics’ & Task Shifting

There have been some global trends toward professional task shifting, now increasingly contemplated and advocated worldwide following WHO initiatives to reach out to very poor countries, which lack properly trained medical personnel.

This essentially means that so-called ‘simpler’ healthcare responsibilities would be shifted down to lesser (more specifically and focussed) trained, cheaper to maintain personnel e.g. nurse physicians, medical assistants, pharmacist assistants, etc.

And now during the recent Budget 2010, we received yet another shockwave to the equanimity of our urban GPs—the just announced ‘1Malaysia clinics’ to be manned by medical assistants! One would have thought that this model is a relic of the past!

In the pre-1980s, it is true that we had utilized medical assistants and ‘jururawat desa’ to help out in more remote rural clinics. They certainly provided a great much needed service then.

But, these are now increasingly scaled down so that doctors can oversee more and more of these services to enhance greater quality and service even to our rural or more remote locales.

Therefore, MMA has immediately opposed what we feel is a hugely retrogressive approach to health care. We are saddened that this approach had been suddenly sprung upon us. We understand that sometimes ‘pork-barrel’ goodies need to be dished out, but we envision these so-called ‘1Malaysia clinics’ as simply exercises to exude political goodwill. This may temporarily salve some very poor urbanites, but we fear that in the longer term, this exercise may be shortchanging the less discerning marginalized public. Regulatory and medico-legal aspects, potential abuses and unethical practices remain to be ironed out.

However, we have counter-offered that our already very available and plentiful GP clinics be tapped to help provide these outsourced MOH initiatives, as more suitable alternatives. We are made to understand that the Minister of Health sympathises with us in this, although it would appear that the MOH has to contend with other Cabinet portfolios for ‘public service’ projects and financial resources…

For our country, which continues to produce so many new doctors—some 2500 per annum, this will be catastrophic for our younger graduates, who might in future not have enough jobs to function, and whose remuneration may be sharply reduced. We need to enlighten the government that this may not be the best approach. Standards of health care cannot be compromised or made expedient just to accommodate to some economic or short-term considerations.

3. CPD/CME & MSQH Accreditation Standards

Another issue regarding professional standards has also to be resolved. As doctors, we must constantly be upgrading our standard of care and professionalism, as well as our currency of our medical knowledge, i.e. we must keep up with CPD/CME activities.

Our clinics and amenities must be enhanced and modernized in keeping with public expectations, keeping cost-cutting measures at a minimum so as not to jeopardize the public perceptions that GPs are only mercenary and venal, and too profit-orientated!

The Malaysian Society for Quality in Health (MSQH) has been set up to help modernize the standards of health care in Malaysia. As a very dynamic entity, it has been working hard to enhance its value by being a lot bolder in its push for more if not all clinics to be accredited as of sufficient quality. This aggressive approach may pose yet another round of regulatory burden on us, the private medical practitioner.

As an initial founding partner, the MMA appears to have been rather silent, in the past. Perhaps to be fair, some of these exercises and progress of the MSQH reach have been hitherto understated, and its potential for burdening the GPs not fully realised. As president just recently exposed to the intricacies of the MSQH exercise, I will work to address such concerns so that doctors will not be subject to any more regulations and new Acts.

Furthermore, we need to work with the Academy of Family Physicians (AFPM) to see if we can re-organise the frame of reference of upgrading and updating our GP/FP practices. At the most, we will accept MSQH as a reference standard purely on a voluntary basis, which should in no way reduce our acceptance with any distribution of work or panels or third party payer contracts or business opportunities.

Most importantly, the MMA needs all your support and members must all come forward to be bold in defending this stand.

Let’s work together to ensure that we provide the best to our patients without overburdening our capacity to cope. Let’s come together to self-regulate and engage in self-improvement techniques, credentialing exercises and standards attainment, which are the hallmarks of mature medical systems the world over.

In this way, we can together persuade the authorities and policy makers that we can be trusted to provide the best and most professional healthcare for all our patients without fear or favour, and certainly not at our professional expense!