And so the Aussies have ventured to set right our stone-aged health care system to see if we can kill less people. Looks like Malaysians cannot do anything right for themselves these days. Certainly any proposal has to be better then anything our clueless Ministry of Health officials can come up with but unfortunately the Aussies have failed to emphasize on one main factorwho holds the money?

And is the MOH, currently so inefficient that ambulances run out of petrol midway to an accident scene, willing to take their fingers off the pies of equipment purchases, bloated IT budgets and crumbling hospital buildings.

When Thatcher ruled and decided the NHS needs new directions she became hopelessly unpopular to the glee of Labour. But Blair didn't do a good job either. He stuffed down doctor's throats MMC's (Modernizing Medical Careers) without their consent not unlike Malaysia's notorious Private Healthcare, Facilities and Services Act immediately alienating doctors provoking them to march in mass protests in London and Glasgow in March this year.

This was followed by the resignations of Professor Alan Crockard as national director of Modernizing Medical Careers, Alex Liakos as adviser to the MMC and Professor Shelley Heard as MMC National Clinical Advisor prompting the Health Secretary Patricia Hewitt to apologize both in public and parliament.

The BMA (British Medical Association) unlike our muted MMA (Malaysian Medical Association) rightly pointed out that apologies were not enough as the entire training system has been put into jeopardy as changes have clearly not been thought through, throwing the futures of doctors and consequently healthcare into disarray.

'I stuffed their mouths with gold'

Till this day if you walk into any NHS hospital you will find notices advising doctors not to cooperate in the MMC. This move has also seen British doctors flying off to Australia and New Zealand for a "better rounded training". Clearly Labour had forgotten the guile of Aneurin Bevan, the guru who was instrumental in the successful initial implementation of the NHS.

Today the NHS is a shadow of Clement Attlee's Labour government's creation following the aftermath of World War 2. When William Beveridge floated this principle of a "cradle to grave" philosophy in 1948, the idea was if full employment can be ensured in Britain, then the cumulative taxation collected could help fund the NHS. Health was deemed a social need not to be compromised and in tandem with Britain's inert principles of being a caring society.

However, Attlee soon ran into serious trouble when funding from the US stopped after Japan was defeated. But Attlee had an advantage in Aneurin Bevan, his newly appointed health minister. Bevan quickly analyzed that he has to first win the doctors over to his side for he reasoned correctly that without doctors, there would be no health service. He offered consultants lucrative payment structures and later stated, "I stuffed their mouths with gold."

Britain at that time was like Malaysia today. Millions who could not afford private healthcare had to put up with third rate services at state run hospitals. Now, every single person had access to quality health care that is financed through progressive taxation.

Till this day, Labour considers the creation of the National Health Service its proudest achievement. Thatcher introduced General Managers into the system and her government subsequently defined the populace as an "internal market". Health Authorities ceased to run hospitals but "purchased" care and services. GPs became "fund holders" and were able to purchase care for their patients. The "providers" were termed independent trusts.

Despite Blair's promise to reverse Thatcher's "privatization" of the NHS, he in fact with Gordon Brown, strengthened it. It suddenly dawned on Labour that healthcare was not cheap. This included the rising costs of medical technology and medicines, the desire to increase standards and an ageing population. Instead they renamed their reforms with terminologies such as detailed service standards, strict financial budgeting, revised job specifications, practice-based commissioning (fundholding again in reality), closure of surplus facilities and emphasis on rigorous clinical and corporate governance including restructuring medical training.

Furthermore Blair's government, whilst leaving services free at point of use, has encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals have been built by private sector consortia. But Blair and Brown failed to see Bevan's logic as to what happens to doctors if the system is privatised. The most famously quoted study is the one by a consultancy company which works for the Department of Health that showed that for every 200 million spent on a privately financed hospital results in the loss of 1000 doctors and nurses.

Oops..the erstwhile creator of one of Britain's biggest asset and icons has got itself tangled so badly that at last call orders were out by the Labour government that the ultimate and if possible speedy target should be that the trusts or authorities or whatever term you would like them called should be absolutely independent. Labour doesn't want its baby anymore. It's an unbelievable headache. And what of its consequences if you want to be paid. Waiting lists cannot exceed six months. So doctors just post their patients to private hospitals where the same surgeons get them done and get the NHS to pay for it which will lead to..you guessed ithospitals and trusts running a financial deficit and getting into debt.

And what of Karl Karol, appointed by the EPU and MOH, to provide healthcare changes to a much vagaried population here in Malaysia not to mention health care staff. Well, they appeared to have zeroed in onto a few points and appear to be here to rubber stamp proposals by the same officials from the MOH who put us into our predicament in the first place.

Government hospitals are today seen as giant, and on quite a few occasions, crumbling mortuaries with babies getting mixed up, dengue patients dying days later with no treatment, specialists who cannot string a proper sentence in English and of course now the home of the infamous petrolless ambulances.

Karl Karol's findings

Health care funding must come from the public's purse and not taxes. Meaning why in God's name are we paying taxes for then? Our education system is in the gutter. Already our graduates have been made debtors for life and Mustapha has even taken it a step further by revoking their civil liberties by taking away their passports after, of course, humiliating them, their family, relatives and friends by splashing their names in our papers about their misdeeds of not paying up their PTPN loans although they may be unemployed.

Our air force copters keep crashing. We pay tolls for our roads. And our soccer team doesn't need our money because I am sure most Malaysians will now agree we ought not to have one. So why do you need our taxes. Oh OK. Inflation, etc, etc.so whatever we are paying is just to "top-up" the short fall.

All government hospitals are to be corporatised for greater efficiency.

This sounds fair enough. Only problem is will the hospitals, just like MAS, Telekom and TNB supposed to continue employing deadwood or can we VSS them and will the government pay them off.

And worse still as in MAS and Proton, will the government continue with its lingering interference by placing retired pengarahs to sit in as directors of these newly independent hospital boards complete with golf memberships, first class travel and holidays abroad? Will politicians walk in and scream "Saya tak mau bayar bill"

There will be integration of the primary health care sector, the government hospitals and private hospitals.

Now this is where it gets tricky. We are not a developed nation...yet. And in fact some areas of the country are very much third world. Our MOH has got this curious notion that clean water, clean air, clean food is not their headache. So what do we do when we get hit by cholera, typhoid, dengue, hand foot mouth disease, SARs, a resurgence of TB, not to mention the ever rising incidence of Hepatitis B and HIV? All to be managed by PFI (Private Finance Initiative)?

Health managers will scream not on your life because it doesn't bring them money.they will go the way of Britain's Trusts, running a financial deficit, getting into debt, filing for bankruptcy and having themselves CTOSed and CCrised. For any nation and especially so a developing one, you privatise primary health care and emergency services at your own peril. This involves national security. You might just as well privatize the army and police force.

Financial incentives shall be the main driver of the system

Are health workers in Malaysia ultimately driven by money? Someone has got this equation wrong here. If you are a doctor having worked in Kapit or Manjung and get kicked about when you are trying very hard to pass your membership examinations on your own and even when you pass, you are told to hang around a district hospital because you don't have the cables, and after passing are continuously bypassed to be replaced by a local specialist much junior to you and further told your postgraduate qualifications are useless, do you seriously think these doctors leave because they want more money.

The "steering committees" advising Karol are a simple case of the blind leading the blind and may be giving this consultant from the outback wrong input causing him to recommend wrong advice.

And what if moneys payable for services rendered by these hospitals are dragged if past standards of our notorious paymasters are anything to go by? Is payment by direct debit or is it going to be 60 to 180 days credit. All these hospitals will wind up if any squabbling regarding payment takes place. But perhaps government hospitals should taste what private hospitals have long since experienced the uncertainty of payment.

And what if consultants are unhappy with the fees offered and like the NHS, tell patients to get themselves admitted to private hospitals and cough up the difference. Driven by financial incentives? Where will the line be drawn and more importantly who in God's name is going to monitor this especially since we lack specialists in almost every sector? Are these doctors going to be paid a basic with a cut in professional fees or are they wholly going to be independent contractors? Who will track them in a 1000 bedded hospital?

Put a better healthcare plan in place (Pt 2)

AHMAD SOBRI is a surgeon who has served in both the public and private sectors in Malaysia for 20 years. He is currently based in South England and his interests include resuscitative techniques including reanimation. His work also includes health policies, planning and finance.