Health Reform: Why We Need Caution & More Meaningful Dialogue (Part 1)... President's Message, Berita MMA, Feb 2011 Dr David KL Quek

Health Reform: Why We Need Caution & More Meaningful Dialogue

(Part 1) 
This has now been published in The Malaysian Insider, 8 Feb 2011 
This is also published in Malaysiakini, 9 Feb 2011

President's Message, Berita MMA, Feb 2011

Dr David KL Quek, drquek@gmail.com

“The Government's response to its consultation on the White Paper, ‘Liberating the NHS’, was a missed opportunity to demonstrate to the profession, and others, that it genuinely was listening to the concerns that many had put forward. We are not opposed to reasoned and evidence-based change, and accept that there needs to be some improvement to the way services in England are planned and run, but it is our duty to speak out when we can see the NHS we care about and work in being put at risk.

“Whilst we support proposals to increase clinical involvement in the design and delivery of healthcare, enable greater public and patient involvement and put the focus on quality and outcomes, rather than crude targets, we have real concerns about other aspects of the planned reforms. In particular, the lack of detail in many areas, the increasing emphasis on competition and the market, and the significant risks created by the process of rushed and unnecessarily risky transition…” ~ Dr Hamish Meldrum, BMA Council Chairman on the NHS Reform[1]

‘Health For All’ 11 years on…

In 1999, The MMA published a monograph on ‘Health For All’, a document, which was intended to promote and urge for a more systematic approach to our healthcare.[2] The MMA leadership then and even now, felt that Malaysia could do better by enhancing our healthcare system so that health equity can be assured for everyone residing in Malaysia—a single payer model was proposed as a possible approach towards ensuring this objective.

In that document, we discussed the dichotomous public-private divide, which was seen as wasteful and occasionally leading to lack of access or affordability for some of the less endowed, the marginalized and those encountering catastrophic ailments.

We lament the fact that up until now, Malaysia still does not have a declared policy of equitable healthcare for all (although in reality the huge healthcare subsidies are considered by many to approach such a system). Ideally healthcare should be freely accessible for all, regardless of ability to pay, and should be based entirely on the basis of need.

Although the social aspects and ideals were widely discussed in this monograph, there was a distinct slant towards social equity taken in the context of the prevailing socioeconomic circumstances then. There was and still is that great need for courageous and prudent leadership in addressing structural as well as financial reform when it comes to healthcare.

Health Systems Malfunction—a Global phenomenon

Simply put, the past 2 decades have seen the unraveling of many health systems even among the richer first world economies globally. Healthcare costs have simply outstripped all economic projections and segued onto exponential trajectories, causing severe strains on national budgets.

Healthcare issues continue to arouse deep-seated partisan passions and disagreements that have become so central as to even destabilize and/or derail governments and leaders! This global phenomenon is now a core sociopolitical issue debated in every nation, rich or poor.

The USA has been struggling with the more inclusive but mandated aspects of Obamacare vs. the Republican Tea-Party push for autonomous patient choice (with zero or as little government intervention as possible) with no regard for the huge 49.6 million uninsured.[3] And the new conservative UK government is trying to dismantle the 62-year old NHS by offering a radical GP commissioning restructuring programme in the vain hope of reducing healthcare costs by some £15 to 20 billion over the next 5 years; this is pitting primary care GPs against tertiary and hospital care.[4]

Surprised? The USA health system is about the most market-driven ever, consuming some US$2.57 trillion (17.3% of GDP!), with arguably the most superlative state-of-the-art care, but with huge problems of inequity: neglected uninsured poor and staggeringly high costs; whereas, the UK system has been a socialized state-organised single-payer system for decades, but with increasingly unmanageable delays and queues angering even the most patient of stiff upper lip Brits!

So what is happening? Such fraying of these entrenched systems is not entirely new. The troubles within the various if disparate health systems have been brewing for some time. The costs and structural tensions have been straining about its seams for decades, and are now finally close to bursting…

So it is questionable who has got its health system right, and it now begs the urgent question that “if it ain’t broke, why change or mend it”? Because, there is no system the world over, which is of one size or one standard that fits all!

Knowledge Economy empowers greater personal choice and demand

Stupendous technological advances, diagnostics and therapeutics, have been so well-publicised that these are creating extraordinary demands for these scarce if initially exclusive and expensive technologies, surgeries and medicines. The result: more and more ordinary people are coveting these life prolonging or health enhancing treatments, all of which are simply overshooting most conceivable health budgets!

Compounding the problem is knowledge explosion and enablement for ordinary people. The Internet and WWW has empowered huge swathes of people with information, and created even more personal demands and wants!

More often than not such ‘k’ empowerment enhances more individualistic tendencies and self-focused behaviour.

That is a given. Knowledge begets personal power. Everyone has become more self-centred and more consumerist. Many are exposed to being more concerned as to individual rights, health and medical possibilities and ‘cures’ for themselves and their loved ones. Many would seek Medicine’s best and especially last gasp therapeutic measures, regardless of costs or actual longer-term benefits.

So, how do we tell different groups of people that not everyone can have everything that he or she desires, especially in the current pervasive free market consumer-driven economy? Open society means non-filtering of data, which in turn means unfettered diffusion of knowledge to all who wish to access such information.

How do we explain self-restraint and eschew selfish demands to instantaneous gratification for quick diagnosis, testing and treatment? Who is to say which patient deserves to be seen first or cared for sooner? Who would have to wait and possibly suffer more pain and/or delayed complications, etc.?

How do we balance such growing demands for better, more select, more costly healthcare for a few, against the greater need for wider lower level primary care for more? How do we damp down these rising costs without appearing to curtail the free-spirited advances of medicine, of science, or the freedom to choose by patients?

Rationalising the need for Reform is not universally an accepted given[5]

How do we persuade medical professionals and patients alike, that perhaps primary care gate-keeping is the way of the future? Would top-down edicts or dictates work? Would our society tacitly allow such a prescription of radical change without adequate consultative debate or choice?

In this day and age, it would be foolhardy to expect that such changes can be brought about without adequate buy in by most if not the majority of the people. This is especially so, when more uncertainties than benefits appear in the preliminary pronouncements of the government, regarding the healthcare reform plans. Slogans such as 1Care remain nebulous and unclear, and are not convincing enough to encourage acceptance by our citizens, and certainly in the current form, not by the medical profession.

Many have asked why reform now? These reforms have been proposed due to concerns that healthcare costs have been escalating, particularly private spending, that there have been too much out-of-pocket (OOP) payments, that there have been possible duplication and wastage of utility of resources, and that the divide between public and private healthcare services have widened to worrying levels.

The MOH believe that the private sector is not sufficiently disciplined or robust in addressing the growth of chronic ailments, and are not promoting primary care and health maintenance enough. The private sector is thought to be too disjointed and have not been providing holistic or family care for patients. The MOH appears unduly concerned that there have been too much doctor-hopping/shopping and thus resulting in poor continuity of care in the private sector. We have asked for specific data to prove this arguable presumption.

Indeed, we have argued that the converse is true in practice. In the private sector, although the cost is higher, more patients and their families follow up with a specific doctor or group of linked doctors, than is the case in the public sector. Most private patients have family doctors who know them and their families intimately. We agree that for the more itinerant patients who doctor-hop around, or those who do not subscribe to seeking healthcare on a regular basis, this might occasionally be a problem.

But for these groups of sporadic and difficult patients, this would almost certainly also be the case within the public sector! We know for fact, that patients following up with outpatient clinics or klinik kesihatan’s encounter a different doctor (MO) almost every time, or a medical assistant, and a different one at best! Most clinical notes and prescriptions are often hurriedly transcribed as harried doctors ‘rush’ to see through the long lines of patients! Otherwise, why should patients pay more to see private physicians, if not for greater personal and more attentive care? Also if patients were really poorly taken care of, surely market forces would dictate a discontinuation of such a failed relationship!

Notwithstanding such a preconception, the MOH understandably believes that its public sector functions more efficiently at offering this modicum of services, touting their capacity at addressing these healthcare concerns from ‘womb to tomb’. We argue that because of debatable accounting methods (which do not take into consideration, infrastructure cost or manpower support staff and wages), the public sector healthcare is more costly per patient seen than that in the private GP sector.

Proposed Gate-keeping role of Primary Care Physicians feared…

One way to reduce healthcare cost is to restrict free access to doctors by any one citizen, especially to reduce self-referral behaviour to specialists and hospital. These have been shown to have an economic conflict of interest, which leads to possible over-use of already available resources and amenities.

So if every citizen can be registered, then this would perforce discipline everyone better to follow a prescribed path of healthcare access, through a primary care physician: whether a GP or a family medicine specialist. More importantly these primary care physicians would be the de facto entry point or access person, from which to approach further secondary or tertiary care, i.e. they function as gate-keepers.

With such a system, it is hoped that healthcare costs can be better streamlined and kept under control. Direct referral to specialists or unnecessary testing or investigations would hopefully be discouraged and reduced, especially if reimbursement disincentives are inbuilt into the system.

Bypass the gate-keeping function of the primary care doctor and such medical bills will not be covered, i.e. this will have to be reimbursed personally, via costly OOP means. Government-assisted payment is only assured when the prescribed pathway is followed. Thus, the plan is to integrate the public-private sector at least at the level of primary care for a start, to create a seamless approach for all citizens.

But can such a system work, especially with our people being so used to the current ‘free access’ mechanism when seeking medical help? Do people want such a change when there would be a drastic restriction of access and care to one doctor? Do our citizens wish to be confined to one GP or FMS for all time? If not, how can anyone change doctors, and how easily can this be done? Would such GPs or designated doctors be forced down on the patients, as already happening with the issue of foreign worker medical examinations? What about free choice, second opinions, etc?

Also how much would this cost the citizen? How much would this restructuring exercise costs? How much would everyone have to contribute to the planned social health insurance (SHI)? Or would such changes only lead to additional costs and additional taxes, without enough tangible benefits or coverage, or possibly with even less access?!

These are the pressing questions and concerns, which have arisen during our dialogue with doctors and citizen groups. Many are extremely worried that leakages (already legend with many government and government-linked entities) and inefficiencies would waste even more money and shrink their already meagre benefits with the current system.

No one is willing to pay more (through the SHI), when they are not reassured that the system would truly benefit them more and reduce OOP and costs! Why change if it benefits only a few concessionaires etc.? We have to address these perceptions, these questions, before we can get support from our increasingly skeptical and knowledgeable citizens.

Practical Concerns remain unanswered

Other more practical questions also come to fore. Can we exert control efficiently enough so that duplication and overutilization of tests and services be truly truncated; that hospitals and tertiary care be services of last and evidence-based needed resort, without aggravating patient safety, endangering lives, even causing delayed therapies, precipitating or provoking complications or deaths?

Who would pay or be responsible for higher chances of medical misdiagnoses, delayed diagnoses, errors and mishaps possibly associated with such rational ‘rationing’ of healthcare?

How do we change physician behaviour that perhaps fee-for-service mechanisms may not be the best approach to rational healthcare cost reform? How do we convince professionals that they would have to accept a new reality and a possible modifying cut in fair wages for fair work based on a new paradigm? Would we be ready for case-mix DRG forms of reimbursements for health professionals as well as for corporate owners of for-profit private medical establishments?

What about the planned commissioning of healthcare services to selected consortia or regional trusts? Would these be carried out without the much-feared corruption or leakages crippling the process? Would private care survive such a change? Or would this go the way of secretive and preferential government-linked concessionaires so much a curse and exemplar of profligate waste and hiked-up costs in recent Malaysian sociopolitical discourses?

How indeed do we revolutionise an entrenched system such as ours, which can lead to probable disruption in healthcare, in reduction of choice for patients, in possible lowered and constrained professional autonomy and remuneration, as well as possible redistribution of resources and re-delineation of authority?

Clearly there is currently neither any simple solution, nor can there ever be.

Let us take the example of the current malaise in the UK’s NHS reform. Health secretary Andrew Lansley has bulldozed his way towards extremely aggressive reform plans, which are now threatening to disrupt the much vaunted if flawed NHS.

Lessons from the current NHS stalemate¹

In the wake of the financial meltdown of September 2008, The Cameron-Clegg administration seems bent on restructuring the NHS to reduce costs. This was unveiled in July 2010. Despite its purported public consultations, its rushed implementation has left much to be desired. But like most authorities, health secretary Andrew Lansley had not waited for much feedback before he unleashed the timelines or the details for the restructuring.

Sadly, this has cast a strong confrontation with the British Medical Association, which represents some 144,000 doctors in the UK. BMA, a doctors' union, argues that the NHS reform plans are potentially damaging. The rushed approach risks pitting groups of clinicians against each other, appearing to encourage competition in saving costs, which might actually be detrimental to patients’ safety. Furthermore, it is not at all assured that this will bring about more prudent use of public money to enable the NHS to save a predicted £15bn-£20bn by 2015.

The BMA warns that there are many aspects of the reform proposals which could undermine the stability and long-term future of the NHS," [6] Other critics of Lansley's strategy, such as the Royal Colleges of Physicians and Surgeons, have also warned that these measures would spell the end of the NHS in its present form.

BMA warns that changing the status of existing NHS providers to foundation trust status has threatened the character and ethos of NHS provision… Deploying more corporate entities could also destabilise the NHS, the security of its employees and their terms and conditions of service, it says.

BMA had also cast serious doubts on many of the policies, which are thought to be vital to improve NHS performance, reduce bureaucracy and improve the outcomes of treatment for patients.

In a robust message to Lansley, the BMA adds: "We urge the government and NHS organisations to focus on those areas where they can truly eliminate waste and achieve genuine efficiency savings rather than adopt a slash-and-burn approach to health care, with arbitrary cuts and poorly considered policies."

The BMA's stance questions the rationale of empowering family doctors fully with unprecedented autonomy, almost total influence over their patients' treatment, and control of the £80bn NHS budget through a switch to GP-led commissioning of healthcare, while leaving out hospitalists and specialist groups, thus leading to possible conflict and disagreements. Such a ‘divide and rule’ approach cannot hope to offer a better, more seamless health service for Britons.

Dr Hamish Meldrum, the BMA chairman, argues that doctors approve of some measures, such as patients having more say and a greater focus on outcomes. "But there is also much that would be potentially damaging. The BMA has consistently argued that clinicians should have more autonomy to shape services for their patients, but pitting them against each other in a market-based system creates waste, bureaucracy and inefficiency."

It appears that governments around the world are not dissimilar… Its pronouncements often have grave and momentous bearings on its citizens and for healthcare and medical professionals as well as for the patients and citizens!

We wait with bated breaths as disruptions and stalemate shake the very foundations in the touted NHS, which model, our very own MOH is trying to emulate!

Let’s hope common sense and a greater consultative approach emerge, with most of the grievances and misgivings given a chance to be resolved for the ultimate good of the public!

---

[1] Hamish Meldrum. New Year message from the BMA's Chairman of Council. 31 Dec 2010. http://www.bma.org.uk/representation/newyearmessagehamish.jsp (Accessed 26 Jan 2011)

[2] MMA. Health for All. 1999, Kuala Lumpur

[3] By Andrea M. Sisko, Christopher J. Truffer, Sean P. Keehan, John A. Poisal, M. Kent Clemens, Andrew J. Madison. National Health Spending

Projections: The Estimated Impact Of Reform Through 2019. HEALTH AFFAIRS 29, NO. 10 (2010). doi: 10.1377/hlthaff.2010.0788

[4] Department of Health. Equity and excellence: Liberating the NHS. The Stationery Office Limited, London, July 2010.

[5] David KL Quek. Health Reform in Malaysia: What should MMA’s Response be? MMA News, August 2010.

http://myhealth-matters.blogspot.com/2010/08/mma-news-august-2010-health-reform-in.html (Accessed 26 Jan 2011)

[6] British Medical Association. NHS reform consultations, responses and briefings. 19 January 2011 http://www.bma.org.uk/healthcare_policy/nhs_white_paper/consultationpaperswp.jsp (Accessed 26 Jan 2011)

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

Bernama Quotes Berita MMA: GPs Need To Change To Face Stiff Competition - MMA President

GPs Need To Change To Face Stiff Competition - MMA President

Bernama news, March 07, 2010 12:58 PMKUALA LUMUR, March 7 (Bernama) -- 

General practitioners (GPs) should revamp themselves in light of stiff competition from government and private hospitals and rapid medical science development, says Malaysian Medical Association (MMA) president Dr David Quek.

Writing in his column in the latest MMA bulletin, he said the role of GPs was increasingly deprecated and marginalised, and added that they were "a marked and endangered species teetering on the brink of extinction".

Doctors, he said, should realise that times and medical practice had changed and they should look within themselves to re-engineer their modus operandi.

"GPs have to emerge from their cocooned complacency that simply serving quietly and earnestly behind long hours of general practice would suffice. It will not," he added.

Dr Quek said the MMA would assist GPs by organising a summit where all issues and their future challenges could be debated to prepare a comprehensive policy.

He said he hoped that doctors in the public sector would also come forward to provide input for the betterment of the profession's future.

In the same bulletin, MMA member Dr H. Krishna Kumar said 4,000 new doctors were joining the profession every year and this posed great competition to private practitioners.

Another source of competition was the improvement of services provided by government hospitals, where there were now more locums to man the accident and emergency departments, thus reducing the waiting time, he said.

Moreover, all state medical departments were continuously improving the quality of care which was patient-focused, he added.

To compete with such developments, GPs should continuously upgrade treatment with the latest management techniques, provide the personal touch, be economically competitive and have flexible hours, and provide quality service, he said.

-- BERNAMA

MMA Seeks Fair Payment For Private Doctors In Government Clinics

MMA Seeks Fair Payment For Private Doctors In Government Clinics

Bernama, March 04, 2010 20:57 PM

KUALA LUMPUR, March 4 (Bernama) -- The Malaysian Medical Association (MMA) on Thursday welcomed the invitation by the Health Ministry to private doctors to serve in the 162 government health clinics nationwide.

However, MMA president Dr David Quek Kwang Leng said he hoped that the government would allocate sufficient funds to allow the private doctors to serve in the clinics.

"It is true that private GPs and doctors are quite interested in helping out with the government initiative to help serve in government health clinics," he said.

Dr Quek said, however, that they had been informed earlier that the first preference for the openings for such locums was given to government doctors and that there was not enough budget to cater for more doctors from the private sector.

He said GPs and doctors in the private sector were keen to work with the Health Ministry to deal with the shortage of doctors and take part in the scheme.

"There has been no mechanism so far to make this work. Of course, our work must be fairly compensated," he said.

The Health Ministry, in a statement today, invited applications from private doctors registered with the MMA and fulfill the service requirement to serve at the 162 government health clinics nationwide.

Director-General of Health Tan Sri Dr Mohd Ismail Merican said they could work at the clinics on a "sessional" or "locum" basis and be paid RM80 per hour.

The working hours are from 8am to 5pm on normal working days (sessional) while the extended time is from 5pm to 9.30pm on Monday to Friday and 8am to noon on Saturday (locum).

-- BERNAMA

-------------oooooo00000000ooooooo----------------------
Original Press Release (GPs for Government Clinics)

It is true that private GPs and doctors are quite interested in helping out with the government initiative to help serve in government health clinics. The MMA has been urging our underworked GPs to help out if there are shortages in the public sector health service.

However, when this was first proposed some 1-2 years ago, the number of opening for such a collaboration was really too small. When the positions for out-of-office hour locums were announced at RM80/hour, many GPs were very interested and tried to register with the MOH, but were unsuccessful.

It appears that government doctors, from medical officers, administrators, and registrars were all keenly vying to take part in this to earn extra income, thus there were no openings at all for the private sector to help out.

This was brought out in the open to the Minister of Health YB Dato Sri Liow, recently at our dialogue with the Ministry in early Jan 2010. A senior MOH official there, confirmed that the openings for such locums were given first preference to government public doctors, and that there was not enough budget to cater for more from the private sector.

We heard from the Minister that perhaps the MOH can allocate more funds to enable the GPs from the private sector to participate. Until now we have not had any feedback.

Thus GPs and doctors in private sector are very keen to work with the MOH to answer to the shortage of doctors if this were true. There has been no mechanism so far to make this work. Of course, our work must be fairly compensated.

We understand from our public sector members,  that there has been a fairly large reduction in government hospital and clinic expenditure budgets, some by as much as 50%. So it is unlikely that the MOH can afford to extend this mechanism to utilise the services of the private sector.

The MMA maintains however, that more medical officers should be deployed to ensure that every health clinic be manned and  supervised closely by doctors, so as to provide a minimum of standards of care for our rakyat, whether rich or poor.

Dr David Quek,
President MMA

Extraordinary Doctors: Johor Bahru: Dr Ho Ung Chek

Extraordinary Doctors: Johor Bahru: Dr Ho Ung Chek

 

by Dr Tan Chow Wei

 

I am proud to be one of the very few doctors who knows Dr. Ho Ung Chek personally and still keep in touch with him by phone almost on monthly basis (in fact, just had a long chat with him 2 days ago).  

 

Dr. Ho Ung Chek is truly a legend.  His popularity is not due to eloquence of speech (David Quek rightly noted that he spoke little but yet able to command respect from his patients).  He was also humble enough to admit what he was not sure.  

 

25 years ago when I was the first GP to practise abdominal ultrasound, he used to refer suspected gall stones, renal stones, fibroids, and ovarian cysts to me for "confirmation", and I found him to be right >90% of time, just based on good old "history & physical examination"!  He also referred his patients to me for ECGs.  

 

Those were days before the birth of Johor Specialist Hospital and other private hospitals.  That's how we became good friends and colleagues.  When he retired and sold his clinic (alas, now closed due to poor management),  he wrote case summaries of his most faithful patients and told them to come and see me. That's why I need to "report" to him regularly --- mind you, he knows all his patients by name together with names of their family memebrs!). 

 

Little known is his special interest in Multiple Sclerosis which he managed with remarkable results with interferon and regular doses of bee venom therapy (Apitherapy).  One of the patients we co-managed is a 50+ year old Chinese lady who was quadriplegic and half-blind due to MS, and was in severe depression.  When started on BVT, she made such progress that she is now able to move around in a wheelchair and has regained motor power of both hands to grade 3.  Just saw her last week in my clinic, she cheerfully told me that she is looking forward to hold up in her hands her 1st grand child who is arriving in June this year.  

 

In Monash where I am teaching Family Medicine, the Year 4 curriculum has now been revamped to put the highest emphasis on GP, on top of Pychiatry, O&G, and Paediatrics. 

 

I believe that the future is still bright for general practice if we as GPs do not allow ourselves to degenerate into "cough-and-cold" doctors but instead to upgrade by CME/CPD so that we can hold our heads up as "specialists in the breadth of medicine". Woe to those who resist change and refuse to learn, for medicine is always a life-long learning experience.

 

Dr Tan Chow Wei, is also a GP and attached to the Monash University Medical School, Johor Bahru, as Professor of Family Medicine.

The GP Conundrum—Whither the Future?

The GP Conundrum—Whither the Future?

Dr David KL Quek, MMA News, February 2010

“A doctor must work eighteen hours a day and seven days a week.  If you cannot console yourself to this, get out of the profession.”  ~ Martin H. Fischer

“A physician is obligated to consider more than a diseased organ, more even than the whole man - he must view the man in his world.”  ~ Harvey Cushing

“To me the ideal doctor would be a man endowed with profound knowledge of life and of the soul, intuitively divining any suffering or disorder of whatever kind, and restoring peace by his mere presence”.  ~  Henri Amiel

“Despite all our toil and progress, the art of medicine still falls somewhere between trout casting and spook writing.”  ~ Ben Hecht, Miracle of the Fifteen Murderers

Of late the general practitioner (GP) has become a marked and endangered species, or so it seems.

The private medical practitioner, for so long the backbone of the primary healthcare structure for Malaysia appears to be teetering on the brink of corrosive extinction, if not emasculation. The GP’s role has become increasingly deprecated, marginalized and severely delimited, even competed against directly and indirectly by government-backed 1Malaysia clinics, run by medical assistants and nurses.

This is especially poignant when we know that whenever someone falls ill and/or needs medical care, some 62% of our nation’s population would seek direct treatment from GPs for the initial health concerns (3^rd National Health & Morbidity Survey, 2006).

GPs remain the very affordable, conveniently-sited and perhaps the most efficiently accessible approach for primary healthcare for most urban as well as for suburban citizens.

Yes, it is true that many of these encounters are reimbursed from out-of-pocket (OOP) mechanisms, which seem to bug health economists these days. But, the cost of such one-to-one care, then and now is still very reasonable and affordable, and often does not escalate as high or as frequently as inflation!

In more rural or remote locations, many patients often find hard-earned means to seek treatment from caring family-based GPs who are often the preferred healthcare provider, rather than to avail themselves to public healthcare clinics where wait times and changing personnel provide a less than continuous system of care. Many have complained of disjointed, impersonal care, which appears to be inherent in our present public healthcare system of rotating transient medical officers or assistants, who come and go…

Thus, despite lingering perceptions by certain authorities that the care provided by GPs are piecemeal and sometimes fractured and deficient, many people when asked would declare that in most cases, the care provided by GPs are what had made our Malaysian citizens as healthy as they have been these many decades following Merdeka!

More than the usual coughs and colds, cuts and scratches, fevers and diarrhoeas, chronic ailments (such as hypertension, diabetes, asthma, arthritis, etc) are also given sufficiently good care by many GPs who provide comprehensive medical services to entire families and their children’s families too. Sometimes, different GPs acquire different reputations for being that singular ‘specialist’ for unremitting fevers, for hypertension, for asthma, and so on.

When I was young, Dr Alice Low from Johor Bahru saved me many times over from my debilitating asthmatic attacks, and generously provided sampled inhalers when my family could ill afford to buy them on such a regular basis. Despite my nearly monthly attacks, I was thankfully, never ill enough to have been hospitalized due to her dedicated care, nearly a half-century ago. I finally outgrew my wheezy tendency in my mid-teens, perhaps a legacy of her care and therapy. Thank you Dr Low!

 

Dr Alice Low (84yrs, left standing), at Dr Martin's 95th birthday, seated. Photo Courtesy Dr Wong Yin Onn, JB

My late father, who passed away at 80 years last year, had severe hypertension from young. He received ‘special care’ from Dr Ho Ung Chek along Jalan Terus, JB, for nearly 20 years. When Dad finally died, he did not have LVH, but the scourge of microvascular effects led to some mild Parkinsonism. He did not have the privilege of better, more efficacious drugs then. But I am convinced he did get the best that medicine and good doctoring could provide then, under those trying circumstances, at affordable and cost-effective prices.

Dr Ho used to work very long hours, from 9 in the morning to nearly 9 at night, six days a week. I did not remember a time when he took leave. When I accompanied my Dad sometimes on Saturday afternoons, Dr Ho was always there for his throngs of patients who would patiently queue for hours to access his ‘special’ touch, his singular ‘knowing’ therapeutic expertise! He spoke little, but had a kindly, approachable façade and calm nature that belies his true quiet authoritative professionalism. In some ways doctors such as these have helped nurture my enduring interest in medicine.

I salute Drs Low, Ho and all others who I believe continue to live on in the thousands of GPs around the country—plying their dedicated quiet practice, looking after so many patients, so many families, that can only leave behind lasting legacies of health, confident connection and friendship…

But times and medical practice have changed somewhat. It is difficult to quantify how much and how this has impacted upon the GP, the medical practitioner, who engages in direct patient care.

There’s greater depth and breadth of old and new medical disciplines, which necessitate constant updating and continuing professional development (CPD). Knowledge and even basic concepts continue to evolve and shift into more plausible, more evidence-based certainty, although these stand correctible with newer findings and research.

Furthermore, the physician is called upon to withstand the onslaught of rehashed mumbo-jumbo and complementary alternative therapies, which continue to mindlessly but alluringly erode into the impassive cold sanctum of scientific medical practice.

The doctor has to steel himself/herself from such quackery, which is seductively simpler to adopt and to share folie-a-deux ideation with our increasingly credulous patients (and even some doctors themselves!). Many are generally becoming more gullible than scientifically rigorous! How can we differentiate truths from pseudoscientific gobbledygook, and avoid the lure of lucre from overwhelming our humdrum practices?

The question arises whether the ordinary doctor can maintain his level of competence and knowledge base so as not to endanger his ward—the patients. Worldwide, the medical practitioner is called upon to maintain his expertise and standard of care, his core competency through rigorous and standardized continuing educational programmes. Most are voluntary, but increasingly, many regulatory authorities are beginning to impose mandatory proof of keeping up with currency of medical knowledge.

Unfortunately however, there has been a general passivity about many of our GPs, our doctors here in Malaysia. It is estimated that as few as only 10-15 percent of our doctors routinely attend CPD programmes. The majority simply sit on their past educational base, and continue regardless without venturing into newer advances in a systematic way.

This will have to change. Doctors have to be more proactive in learning and maintaining their skills and knowledge, if they are to do justice to their profession, no matter their conviction that ‘all’ of medicine had been learnt in his/her tenure as a medical student! So how do we encourage or even mandate such a change, a requirement, to ensure that modern medicine is now as scientific and as evidence-based as can be?

GPs must look within themselves to re-engineer their modus operandi, their ways of medical practice even. GPs have to emerge from their cocooned complacency that simply serving quietly and earnestly behind long hours of general practice will suffice. It is not.

More is now expected, it is no longer simply more of the same, with an unending gravy train of endless patient queues. Fee-for-service models may also need a re-tweaking, as more and more primary care services are moving toward a capitation/gate-keeping and pay-for-performance model.

Will the solo practitioner be extinct? Can he/she cope with the rising expectations and keener competition to be better, more efficient, more diverse yet more encompassing?

Or would larger group practices with greater diverse interests and greater pooling of resources and capacities be the trend for the future?

There is louder and louder talk of locale-base patient-registered medical practices which will be regionally reimbursed through a single payer system. Will the GP be prepared, and if so, how can this be made better or improved upon? There is also talk of co-payment possibilities to reduce abuse and over-use of amenities or medications, even separation of pharmacy-dispensing roles…

Would the GP be ready to act as responsible financial-controller and gate-keeper, with that onerous duty on who to continue to treat and who to refer forward to tertiary specialist care, on a timely yet medically-defensible way?

Would he or she be ready to look after returned patients, who have been referred back for chronic care management and rehabilitation, after acute tertiary therapies, including major surgeries?

Will our GPs be up to the mark of being the primary care-led physician who can help keep the cost of health care as low as possible?

Would the GP be trusted to ensure that the societal interests be the primary concern, while maintaining a high performance standard, which enhances measureable and auditable healthcare targets?

Will he or she be ready to be rewarded for performance rather than rely on the lure of pure profits, alone? Are the GP’s skills sufficient at this juncture to cater to these potential and impending challenges?

Therefore, as can be predicted, there will be tremendous emerging transformations, which would continue to shatter the equanimity of more and more GPs—creating in its wake more uncertainties and piqued disappointment.

There is thus, the growing spectre of more regulations, possible accreditation plans for both professional/practice and clinic standards, and possible recertification/revalidation moves which only add to the litany of more bad and cumbersome news.

Then too, there’ve been moves to introduce family medicine specialists (FMS) or family physicians as another tier of ‘specialist’ primary care doctor, who supposedly would be better equipped to enhance modern day primary care practice…

I know that many GPs are quite distressed by all these developments. Many have complained loudly and are understandably angry because they feel so hopeless as events continue to unravel around them with such paces that seem to leave them behind. Some complain that they seem to have been neglected and left out of the loop, whenever discussions on their future take place.

Yet GPs are supposed to have been represented. They have various groups, which purport to be acting on their behalf, with the MMA being the largest body representing them. Yet, these do not appear to be enough. Whenever any call is made for GPs to come forward to be heard, only a select handful turns up to be counted.

In January 2010, in the wake of the contentious 1Malayia clinic launching, a dialogue with the Health Minister saw just some 13 GPs out of 25 MMA members, who could find the time and effort to make a presence, and let their voices be heard.

This perceived apathy and lack of forceful passion is deafeningly disturbing, and gives the impression to the authorities that GPs are malleable and thus perhaps can be led without too much pressure. Thus, events continue to unfold, and the dice appears to have been cast…

But the brutal honest truth is that GPs appear to be floundering, like fish out of water. The tide of good ole times seems to have ebbed. We appear not to have a cohesive or comprehensive General Practice policy, which is devised by GPs themselves, when this should really be the optimum practice.

As president, I have been publicly censured for opposing the popular 1Malaysia clinics, and told in no uncertain terms that I should simply lead, and that the GPs would follow. Even another medical group leader suggested that since some proposed changes are good for the profession, such upgrading efforts should be pushed and led, not necessarily with input by the GPs on the ground! Lead, not by consensus or feedback all the time, I’ve been told… Let a few disgruntled ones make some noises, but as leader, just do the ‘right’ thing by what MOH or some of us, feel is right…

But I choose to listen to the background noises, because many GPs did email or sms text me their rising discomfort level, their rightful concerns, their livelihood realities, their professional right. Yes, we do need more doctors to speak out and be counted. Now we should do even more!

It is with this in mind that the MMA has through its PPS, initiated a Primary Care Group which is striving to champion the policies of the GP. The Academy of Family Physicians, and some interested GP interest groups are also involved.

We are planning a GP Summit where we hope all the issues, which pertain to the GP and its future challenges and scenarios can be discussed, debated and finally arrived at, in a comprehensive policy document which will enhance and protect the interests and ultimate practice conditions of all GPs.

We need as many of you as possible to support this initiative. Do come forwards to make this a great success with all your input, to help shape our collective future! This is in your hands!

For those in the public sector, it is also incumbent on most of you to consider seriously that your future would also depend on the many policy changes, which are coming on-stream very soon. You too must come forward to join us in the campaign to ensure that our voices about our future be heard.

For once in a long while, please come forwards and make your own future! Doctors of Malaysia, it is time to unite and be counted, lest we be accused of engineering our own demise through neglect and apathy…