Friday, 20 March 2015

Egyptian Health Service

The British National Health Service (NHS), the top model of a nationalised health system in the world, has recently been suffering a lot because higher costs have to be covered and now the private sector is apparently essential to maintain the NHS. It helps with the workload, brings new skills, and contributes to competition. The term charities or third sector refers to organisations that are not for profit and non-governmental. This is where I currently practise in Egypt. It has been suggested that charities should get longer and more stable contracts than the private sector. It has also been stressed that the NHS will not achieve sustainability on its own; only by working in close partnership with charities will it succeed in adapting to the demands of 21st century healthcare. The original UK GP fundholding concept has been replaced by presence of clinical commissioning groups (partly run by the GPs) but new integrated care systems are being developed.

If Egypt follows the British model, Egyptians are expected to be registered at general practitioners (GPs) units. I dare to say that GPs and consultants should not be allowed to have governmental and private practices together. Moreover, trainees should be in the governmental practices only. GPs decide who can be managed at their units and who to see the consultants. Exemptions can occur such as in emergencies and when seeking sexual health service where patients can directly seek the consultants help. The patient should be able to change the GP, whether governmental or in the third and private sectors, as long as the patient is in the catchment area. The have-nots should be offered GPs services gratis.

In my opinion, the Ministry of Health role in Egypt should be limited to the following:
1) General Public Health measures e.g. water and food safety, vaccination programmes and pricing drugs.
2) Governmental GPs units: GPs who are employed by the Ministry of Health should be given the necessary funds to cover management and referrals of patients. I do think that they are the suitable personnel at the Ministry of Health to choose what is best for their patients using the funds to cover the expenses of diverse spectrum of providers including the third and private sectors. Governmental GPs (fund-holders) should normally pay the consultants fees and treatment expenses whether in the governmental or the third and private sectors but if the funds cannot cover such expenses, the GP should choose the consultants who can see and manage the have-nots gratis or with sliding fees (if compatible with the taxes system). A list of these consultants should be available to all GPs, nationwide, and to the public. It should be kept up to date.  

Where appropriate, Ministry of Health hospitals can be turned into university hospitals (nearest Faculty of Medicine) and all university hospitals can follow the British NHS model. The rest of the Ministry of Health hospitals can remain as such where appropriate but become independent of the Department of Health (hospital trusts following the English NHS model in particular) or be sold to the private sector if they fail to function satisfactorily. Teaching, research and trainees salaries should be separate from consultations/treatment fees (including fees in the form of a salary).

It is very interesting to note that Canadian healthcare services (Canada is still a constitutional monarchy where the British monarch is the head of state and a federal parliamentary democracy) are largely delivered privately, but funded publicly - typically a fee per consultant service not a salary (though new entrants might prefer to change the system from fees for service with no pensions to classic salaries - pensions system)Costs are paid through funding from income taxes. Health Act does NOT generally cover prescription drugs, home care or long-term care, prescription glasses or dental care, which means most Canadians pay out-of-pocket for these services or rely on private insurance. Cosmetic surgery is generally NOT covered. The government does NOT participate in day-to-day care or collect any information about an individual's health, which remains confidential between a person and the physician/surgeon/family doctor. Administrative simplicity dominates the process where in each province, each doctor handles the insurance claim against the provincial insurer. 

Actually, I do think that the current Canadian system not covering certain aspects in healthcare is a reasonable one that better suits Egypt (but with the classic salaries - pensions system)
Primary care is the foundation of the Canadian healthcare system but patients can have direct access to consultants without needing a GP referral. The College of General Practice of Canada was founded in 1954 but in 1967 changed its name to College of "Family Physicians" of Canada.

Egyptian College(s) should be established as soon as possible (there is only one Royal College in Canada for Physicians and Surgeons). There is a need for major law changes in order to replace the current MSc exam with a national membership exam. I envisage, in the future, membership of the Egyptian Colleges will be considered a mark of excellence replacing the old variable standards in Egypt. A national certificate of completion of training (CCT) should also be introduced and continuing professional development (CPD) credits awarded. The Egyptian Medical Syndicate headquarters should be renamed the Egyptian Medical Council or that the Council should be established independently. Likewise, there is a need for an independent medical protection society to provide the best possible protection and peace of mind for medical professionals throughout their careers. This role is currently partially played by the Egyptian Medical Syndicate.


سؤال متكرر: اين عيادتك الخاصة في مصر الان؟ لا توجد. اعمل بعيادات للعمل الطبى الخيرى كلما سمح وقتى ولا اتقاضى راتب او اتعاب منها. يسمى هذا القطاع بالقطاع الثالث لانه ليس حكوميا ولا خاصا يهدف الي الربح. لماذا اخترته؟ اخترته بعد رحلتى في كل من القطاع الحكومى ثم القطاع الخاص ومن التجارب المستفادة. سؤال اخر: هل هذا هو الاختيار الامثل لك؟ الحقيقة لا لانى افضل دائما انا اعمل داخل نظام قومى يعتد به مدعم بالقطاعين الثاني والثالث كما هو الحال في بريطانيا مثلا رغم ما تعانيه من مشاكل شرحتها فى المقال اعلاه. لكن هو الاختيار الانسب لى في مصر بعد الخبرات المكتسبة. لم اسجل لممارسة الطب الا في بلدين بلدى الحبيبة مصر وفي ام الطب بريطانيا

خواطر من الماضي

لم افتح عيادة خاصة في مصر إلا بعد استقالتي من الحكومة. تحيرت كثيرا في تحديد قيمة الاتعاب ولم اتحير ابدا في القاعدة العامة "مجانا لغير القادرين" وكذلك قاعدة "مجانا لاهل المهنة ومن يعولونهم". منطقيا تزداد قيمة الاتعاب وفقا لازدياد التضخم ولكني وجدت ان مفهوم ال
 sliding fee 
هو الانسب بمعنى ان قيمة الاتعاب تقل وفقا لميزانيتك

عن نفسي طبقت ما تنادي به حاليا نقابة اطباء مصر (دار الحكمة) ولكني طبقته سابقا طوال فترة عملي الحكومي في التسعينات حتي الاستقالة لاني رأيت ان هذا حق المريض في اماكن عملي الحكومية. يقصد بالعلاج المجاني العلاج باجر رمزي جدا (تذكرة الكشف تتراوح من 1 الي 3 ج حاليا). بدا يومي مبكرا وانتهي متأخرا مرورا بما يسمى العلاج الاقتصادي ثم ما يسمي العلاج المتطور بنفس التذكرة (تذكرة ما يسمى بالعلاج المجاني) طوال اليوم فضلا عن عملي في الاقسام الداخلية. هناك من اعتاد سؤال المريض من تنتظر بهذه التذكرة والاجابة انه ينتظرني ولي الشرف فاذا رغب المريض في صرف ادوية من المستشفي تصرف فقط بتذكرة الاقتصادي او المتطور قام بذلك اختياريا ونفس المنوال في الاختبارات وكنت سعيدا بتبرع امريكا حينذاك بمعمل مجاني تماما لكشف الامراض المنقولة جنسيا مما ساعدني على عمل رسالة بحثية كما يجب ان تكون. هل واجهت مشاكل؟ نعم بالطبع انتهت بالاستقالة ثم العودة الي بريطانيا. سقط والدي الراحل مريضا عندما كنت في بريطانيا وبعد وفاته، واجهت مشاكل في الميراث لسنوات عديدة، وكنت غير متأكد أين أفضل الاماكن لمواصلة حياتي المهنية ولكن في النهاية قررت البقاء في مصر محاولا المساعدة في اعادة بنائها رغم أني أفهم تماما أنه من غير المحتمل أن ارى التغييرات المنشودة في حياتي. هل ندمت على الاستقالة؟ لا اطلاقا بل تحررت واخدم بلدى وفقا لمعايير ارتضيها ومجانا لغير القادر (حينما كنت في القطاع الخاص). البركة فى حضراتكم ايها الجيل الصاعد لترون مصر افضل ان شاء الله. قد تسمون ذلك هروبا ربما ولكن التناقض احساس صعب جدا

اعادة بناء مصر طبيا

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Main Works of Reference List (The first eight are my top favourites)

  • British National Formulary
  • British National Formulary for Children
  • Guidelines (BAD - BASHH - BHIVA - Uroweb)
  • Oxford Handbook of Genitourinary Medicine, HIV, and Sexual Health
  • Oxford Handbook of Medical Dermatology
  • Rook's Textbook of Dermatology
  • Simple Skin Surgery
  • Weedon's Skin Pathology
  • A Concise Atlas of Dermatopathology (P Mckee)
  • Andrews' Diseases of the Skin
  • Andrology (Nieschlag E FRCP, Behre M and Nieschlag S)
  • Bailey and Love's Short Practice of Surgery
  • Davidson's Essentials of Medicine
  • Davidson's Principles and Practice of Medicine
  • Fitzpatrick's Colour Atlas and Synopsis of Clinical Dermatology (Klaus Wolff FRCP and Richard Allen Johnson)
  • Fitzpatrick’s Dermatology in General Medicine
  • Ganong's Review of Medical Physiology
  • Gray's Anatomy
  • Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery
  • Hutchison's Clinical Methods
  • Lever's Histopathology of the Skin
  • Lever's Histopathology of the Skin (Atlas and Synopsis)
  • Macleod's Clinical Examination
  • Martindale: The Complete Drug Reference
  • Oxford Handbook of Clinical Examination and Practical Skills
  • Oxford Textbook of Medicine
  • Practical Dermatopathology (R Rapini)
  • Sexually Transmitted Diseases (Holmes K et al)
  • Statistics in Clinical Practice (D Coggon FRCP)
  • Stockley's Drug Interactions
  • Treatment of Skin Disease: Comprehensive Therapeutic Strategies
  • Yen & Jaffe's Reproductive Endocrinology