8 April 2000

Contracting out government clinics must proceed with care

(Keywords: out-patient clinics, contracting out, public health, HMOs)

          As the debate on a possible health care reform heats up and the promised "Green Paper" still in possible difficult elbow, it becomes obvious that any pragmatic health care change extends much more than health care financing charges. Of late, media attention has focused on the contracting out of the general out-patient clinics of the Department of Health (DH).

          In the core of discussion must be the current role of DH and its possible changes in the future for a better, more efficient and more cost effective health care system for Hong Kong.

          Since as early as 1988, myself and the medical profession have been calling for a revamp of the role of the DH.

          As a start, the DH currently is involved in health prevention, disease surveillance, data collection and analysis. These must be the major functions of DH and it is what public health is all about.

          The DH is currently also the controller of private hospitals and clinics. It also runs some 64 general out patient clinics, health screening for students, elderly and women, dental services for students and civil servants, etc.

          As a Jack of many trades, the DH falls victim to be "master of none".

          To wit, monitoring of private hospitals and clinics has always been done on a half-hearted basis and the role as controller has been more in name rather than in deeds. It is only through the wisdom and initiation of the private hospitals that their own self-financed impartial standard vetting measures are being in place.

          The general out-patient clinics, occupying only 15% of overall primary health care market, are another "sore thumb". In the past, these clinics were merely providing the bread and butter for common-a-garden illnesses. Yes, there have been improvements; yet still far from satisfactory -- opening hours may not blend with public needs; there is fixed quota irrespective of demand; and it is far from what proper family medicine practice should provide. Worse, the cost is markedly in excess of the private sector.

          Contracting out these clinics thus could be a step not only for enhancing cost efficiency, but also relieving the over-stretched DH staff to deal with other "public health" matters.

          Whatever its merits, any contracting out must satisfy the needs of: affordability to the public; acceptable standards; provision of training for family medicine; and facilities for data collection for disease surveillance.

          Affordability is a key issue. Whilst the principle should be those who can afford should pay, health service must be offered with the minimal fuss to the needy. One suggestion is to issue to those on social security or unaffordable, after means testing coupons, with which their attending doctors could be reimbursed by government. Equity could thus be assured and possible discrimination could be minimized. After all, those affordable pay from their wallets whilst those unaffordable pay through coupons.

          On assurance of standards, it is imperative that specific criteria be laid down in the contracting out agreements. Such criteria could base on infrastructure of the clinic, qualifications and continuous professional developments of the practitioners.

          Hong Kong has a shortage of family medicine specialists due mainly to the shortage of training facilities. Out of the six-year training programme required for family medicine, two must be in recognised training clinics. Regrettably, despite having six such recognised clinics, the DH has no plans for such training posts. Any contracting out scheme must, therefore, give thorough consideration for assuring sufficient training facilities and opportunities for family medicine for public good.

          Contracting out clinics will no doubt wet the appetite of the profiteering Health Maintenance Organisations (HMOs). Government is well advised to introduce legislation to control these organisations from controlling the professional autonomy of their contracted health care providers in the provision of the best care for their patients. It must be realised that with a capped cost to provide medical care, the less investigations for patients albeit necessary, the less expensive treatment albeit justified, the more will be the profit of these HMOs -- all at the expense of the patients' well being and the doctors' integrity.

          Meanwhile, the medical professionals are well advised to move with unity in organising their own professional yet non profiteering managed care set-up. Such set-up can contest for contracting out clinics and, with no middle agent, provide the most cost efficient service to the public.

(Hongkong Standard)