OUR healthcare facilities may not have the best ambience, health information systems and parking space but we probably have the best doctors in the region.
Best not only in our varied and par excellence clinical expertise but also in our contributions to humanitarian needs nationally and internationally.
The top three charitable organisations in the country are headed by clinicians, debunking the notion that medical practitioners are only obsessed with the bottom line.
Most importantly, our nation’s doctors take pride in their work ethics and work culture, believing that their needs and development will be taken care of so that they can focus on what matters most – caring for patients.
However, we are concerned to hear about the rise of a toxic work environment that is increasingly pervasive in the Health Ministry (HM), described as a culture of fear and intimidation.
Our article titled “Healing the healing profession” addressed the bullying work culture that is chronic and perennial in the HM.
More recently, we condemned the culture of pilih kasih (favouritism), which is prevalent in the HM and everywhere else in the civil and political service, calling upon these leaders to stop all forms of discrimination, from the minister and director-general right down to the head of departments (HoD).
The underlying issue boils down to the same thing – the organisational culture of the HM.
While the HM’s vision and mission statement look impressive and is displayed on the walls of the Putrajaya office, are they being translated into the work culture of all the personnel across the board?
Unless all the HM leaders, from the senior directors and directors in Putrajaya, states, hospitals and health centres, open their eyes and hearts to recognise and acknowledge that critical action is needed urgently, no healthcare transformation plan will work.
This includes the Health Minister’s noble and strategic plans for Electronic Medical Records, Health Financing and “Sihat Bersama 2030”.
Healthcare reforms can only be possible if all the HM leaders and personnel adopt a supportive and forward-looking approach to tackling the current mess, and work together as one to create a healthcare system that is value-based, patient-centric and professional.
Culture change starts at the top
The political and clinical governance in the HM has been appalling in the past few years, with everything coming to light during the Covid-19 pandemic.
Healthcare providers themselves recounted the horrors, for example: “June and July 2020 were horrible, and patients were dying like flies. It was the worst time of my life. Even palliative care was not allowed for the terminal Covid-19 patients.”
This is a clear testament that the country cannot afford healthcare leaders who do not have a heart to care, let alone cure. We need leaders who are receptive to other opinions and allow other voices around the table to be heard.
The HM leaders must practise and inculcate a culture of transparency, accountability and honesty to encourage an inclusive and comprehensive exchange of ideas. Affective and effective leadership is key to building great organisational cultures.
Culture change starts with behaviour change
Change by itself is prone to resistance. What more when trying to change the culture of an entire organisation like the HM.
Ultimately, culture change is a long-term initiative, and it must be a whole-of-ministry effort. This arduous task, best described as a system overhaul, involves shifting mindsets, starting from the top.
To begin with, the HM needs leadership that is committed to change – setting the tone, establishing expectations and leading by example.
Strong leadership will help direct healthcare providers towards the much-coveted reforms within the system. This is where clinical governance is paramount.
Reinforcing clinical governance
Clinical governance is the framework that holds healthcare organisations accountable for continuous improvement in the quality of their services.
Clinical governance typically covers seven key pillars – Patient-Centred Care, Clinical Effectiveness, Patient Safety, Governance and Leadership, Information Management, Training/Education and Performance Monitoring.
A strong clinical governance framework within the HM will protect the delivery of quality and safe patient care that adheres to ethical and legal principles.
At the heart of clinical governance is culture and leadership. Here are some recommendations for the HM’s consideration:
The health minister, director-general and secretary-general must deep dive with the National Head of Services to drive this message about clinical governance without sugarcoating.
The HM must be led by a strong leadership that is fair, inclusive and receptive to ideas and positive change. As such, all the highest posts must be interviewed and elected rather than appointed.
Leadership means the ability to bring out the best in others and mobilise their talents towards the hospital’s goals, values or outcomes. Clinical HoDs, hospital directors and state health directors must lead by example by displaying unequivocal commitment towards quality patient care, ongoing improvement and outcomes.
The term of office for HoDs is two years. To ensure performance is maintained, his/her reappointment must be based on an objective assessment that includes 360-degree feedback.
Zero tolerance for unethical and illegal practises of HoDs and clinicians who abuse their positions to benefit personal interests, for example, doing ward rounds or surgeries in private facilities instead of teaching rounds with their staff, and abusing hospital facilities to benefit their private patients. The clinical governance must take stern disciplinary action against hospital and state directors who are aware of yet condone such moonlighting practices.
Service memory must be included for specialists who have served in different places but are not promoted because they are unknown to the latest supervisor. There are many senior clinicians in the UD56 grade since 2017, whose seniority and contribution deserve due recognition and promotion to Special Grade C. These senior doctors, who are bastions of the healthcare and have served faithfully for many years, are not holding Jusa (public sector superscale) posts. They will most likely to resign unless they are promoted and remunerated accordingly. The minister and his promotion board must give the senior clinicians with the UD56 grade special consideration at the next meeting with the Public Service Department and finance minister, or risk losing a large pool of expertise and experience in healthcare.
Subspecialists, especially in non-surgical based subspecialties (except for neurology, oncology, respiratory, nephrology, intensive care and cardiology, who have enough workload) must continue doing general clinical work. There has been a worrying trend in recent years of subspecialists in some disciplines refusing to do general clinical work.
Almost all hospitals have at least six to eight specialists in each department. However, many specialists are not doing active stay-in on-call duties, resulting in patients not getting adequate specialist care after office hours. The HM must make it compulsory for specialists in major disciplines, for example, Medicine, Surgery, Obstetrics, Paediatrics, Orthopaedics, Anaesthesia and Emergency Medicine, to do active stay-in calls if there are at least eight clinicians (inclusive of consultants and specialists under gazettement) in the department.
Previously, medical officers from district hospitals and health clinics would refer patients to medical officers in tertiary hospitals. Now that hospitals have more specialists, patients should be referred to the specialist on call to relieve the work burden of junior doctors.
Create a pathway for specialists who have resigned for various reasons to re-enter the service with attractive personal and career development incentives. Remember that healthcare professionals, like any other professionals, deserve opportunities for advancements to better serve the healthcare system. They will, in turn, pass the baton to the next cohort in the future.
Leadership and communication skills are critical in today’s fast-paced globalised world. The HM needs to continuously hold leadership training programmes to inculcate leadership qualities in future clinical heads. Currently, almost all leaders are appointed based on seniority, not capability. These trainings should start at the medical officer (UD48) level, with emphasis on Servant Leadership so that clinical heads and hospital directors are trained to serve and prioritise the organisation first before self.
It has been said that a fish rots from the head. The HM can no longer play the ostrich game. It must take the bull by the horns to kickstart real healthcare reforms before it is too late.
Comments: letters@thesundaily.com
