Primary health care reform must move away from public vs private notion

Primary Health Care (PHC) reforms must be based on the registration of an individual with a doctor of his/her choice and the need for doctors to organise themselves in group practices.

Government has acknowledged these basic requirements in the recently published consultation document. However, I fear that some points will hinder the process towards successful implementation of the reforms.

The reforms must move away from the obnoxious idea of 'private' versus 'public' health care. Such a distinction is antiquated and serves to create discrimination in how one treats patients or how one looks at those using one type of service against the other. Such distinctions are odious and cannot be tolerated; medical services are humanitarian services. All deserve the best level of care irrespective of everything else. Hence, there should be one good system accessible to all.

I also disagree with the government's decision that it "will not contribute directly towards coverage of patient consultation fees with a private family doctor". Such a decision cannot even be conceived if there was only one system in operation.

A payment system needs to be devised so that the triad patient-state-insurance is involved in settlement of medical fees, the burden being shared depending on pre-determined criteria.

Patients should pay for the service and a part or all of this fee would be refunded against a receipt issued by the practice (and no more tax harassments).

There are other options to consider but certainly the idea of a salary for health workers and a free service at source works against the interest of both the health care provider and the patient, as experience has shown.

Earnings depending on performance will motivate the care givers into giving their best; removing the free-for-all system will reduce abuses currently rampant and costing the taxpayer dearly.

Even if one considers laboratory investigation, one PHC system will ensure that there is no costly duplication of tests, cutting down the waste and increasing efficiency in clinical management.

Furthermore, I believe that each registered patient should pay a nominal yearly "registration fee" to cover doctors' sick leave, vacation leave and study leave to follow CPD (Continuing Professional Development) courses which are mandatory nowadays for specialists to keep their status.

If the reforms are to achieve the objectives of "equity, efficiency, quality and accountability" and "to shift... the workload from hospitals and institutions towards the community", then group practices need to be set up.

These would essentially be made up of three or four doctors, a similar number of nurses, a dentist, two receptionists, one or two pharmacists (one clinical), a physiotherapist, an occupational therapist and a podiatrist.

Hours of work (for doctors) should be chosen by the doctor and in agreement with the particular group practice. Of course, fewer hours may mean that a doctor may not have more than a set number of patients.

On the other hand, a doctor should not be allowed to have more than 3,000 patients nor be allowed to work more than 45 clinical hours/week.

There could be a provision for on-call hours or time spent in sorting out paperwork, checking results, filing, updating medical records, and so on. The system will have to allow for adequate remuneration for these too.

The ideas related to tax incentives, government assistance in setting up clinics, access to computerised records, computer bookings for hospital appointments and so on, are all very positive and should be developed.

Today's health centres should be converted into mini-hospitals for secondary care. Patients who have completed treatment in the major hospitals but are not yet fit enough to return home, could be transferrred to these centres for rehabilitation.

Hospital firms would hand over the case to the patient's family doctor who will take over and supervise further management, thereby ensuring continuity of care which is currently rudimentary at best.

Family members would have the opportunity to get involved too, receiving instruction or some training on how to manage their loved ones should these require further nursing at home. In this way, precious hospital beds are freed for more acute cases.