Draft Speech by Dr C H Leong
"Standard and Quality of the Medical Profession in Hong Kong -
A Response to the Health Care Reform Consultation"
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Hong Kong Former Senior Civil Servants Association
1 March 2001

          May I thank you for your kind invitation to address this very august gathering. Senior civil servants to me are the cream of the society. The fact that you have all contributed significantly to the society as civil servants and have since left the service through one reason or the other really make you the "creme de lacreme".

          The chairman in his introduction mentioned that I currently preside over the Hong Kong Academy of Medicine. Certainly, this body created by statute to set standard for specialists and vet doctors' qualifications to become specialists is very much related to the topic of today. Yet, if you would allow me, I would not be addressing you in the calibre as the President, but rather as an ordinary doctor, a member of the public and perhaps a senior citizen.

Different Views on Monitoring of Standard and Quality

          Many have asked why do we need to set standards and establish quality assurance of health care, for our health care professions.

          To many doctors, they feel that they are practicing "仁心仁術" ("art of healing with a kind heart"). Isn't this enough? Why should there be regulations to control and calibrate them? Let us not forget that health care is an essential service, health is the essence of proper living and health service is something that the public know very little about, relying as it were entirely in the hands of the doctors. It is thus essential that a benchmark be set, a measurement be determined to assure that the doctors are giving the expected services to the public. This benchmarking is made more stringent, the rules more transparent as the society becomes more affluent, more health conscious and more assertive in their own rights, commonly known as patients rights.

          To be fair, standard setting both for registration to practise and to be qualified for specialist status exist today. The former is the prerogative of the Medical Council. Specialist registration is also the duty of the Medical Council in line with the yardstick determined by the Academy of Medicine. These bodies are not only empowered by law to refuse registration and remove doctors from the registry, but also to impose any disciplinary measures short of deregistration bringing the doctors' name into disrespect and shaking their immediate livelihood.

          But is this enough -- enough to satisfy the insatiable demand of the society, the over-zealous bickering of the media, and more importantly the conscience of the profession that they are true to their hearts providing the highest standard of care, the most up to date advances in medical technology?

          To the critical media, the common behest is that these bodies are constituted mainly by members of the profession and is thus an "inside job" or "醫醫相衛" ("doctors protecting doctors").

          To the public, why should doctors be given a "privileged status", to be monitored by their own peers, when even civil servants and government departments are all under the purview of the Ombudsman, irrespective of rank and seniority?

          Yet, who can judge a doctor's standard except their peers? Who is to say that the appendix operation done by Dr X was not the proper way for that particular patient? Let us do not forget that whilst the Ombudsman should extent its arm to scouting all our mal-administration, standards of medical practice is a professional issue which only the profession has the knowledge and the right to judge and penalize.

Shortcomings in Disciplinary Mechanism

          Is it then that our doctors are already well disciplined? Can the public's mind be set at ease that whatever service they receive in health care is up to the best available standard?

          No, this is in no way what I have implied. Indeed fallacies do occur in our Medical Council and other standard setting and monitoring institutions that leave a lot to be desired and much for improvement. Let me elaborate.

Lacking Quality Assurance

          As it is, there is no compulsory requirement on quality assurance in the work of the medical profession. As long as a doctor perform within the requirement of the Code of Practice and commits no offence, he will not be disciplined and he will be left alone to do his practice. There is no indication how well he is serving his patients. In short, we have a system to assure for a minimum standard, but there is no way for the public to know, and no requirement for the practitioner to achieve, the highest possible standard. Whilst it may be a rather degrading suggestion that all doctors should be gauged for an ISO 9001, some form of rules for quality assurance is wanting in this open and transparent society, where the consumers - in this case the patients - can and should have the right of proper information to make an intelligent choice.

Fallacies in Handling Wrong Doings

          The Medical Council has other restrictions. It does not have the power to instigate investigations and prosecutions on its own. There needs to be a complainant. In the interest of preventing abuse, that complainant against any doctor must be willing to bear witness of the event. Let me elaborate the shortfall with a specific example. Months ago, there was a blatant misconduct act done by a medical practitioner when he advertised himself using other colleagues' qualifications. It was reported in a newspaper with full photographs of the "fraud". Regrettably, the culprit up to today has got Scot free. For whilst it is not the usual thing for a newspaper to bear witness of a misconduct in court, the Medical Council has no right even to go to the site to investigate and take picture, basing on which a prosecution may be the result and a blacksheep of the family be annihilated.

          The current system often leads to doctors facing unnecessary suffering. With the unsympathetic and somewhat prejudiced press which invariably grasp at sensationalism, any mishaps in a health care setting is being labeled as a mishap of the doctors. Yes, doctors are captains of the health care team. Yet they cannot be responsible to wrong doings of the tea ladies in any health care institution.

          Nor is the sensitivity of a doctor's job ever appreciated in handling wrong doing allegation. Doctors' job deals with life. It demands confidence of a patient in placing his/her life into a doctor's hands. All these confidence could be shattered overnight if the details of the doctor alleged of wrong doing were to be publicized uncensored even before and during the disciplinary hearing. Would female patients ever return to a male doctor who was alleged to have sexually assaulted a patient, in spite of his ultimate proof of innocence or even being a victim of a planned "framed up"?

          Are we now in an impasse? Can the patient be assured that he or she is getting the highest and honourable standard of care, at the same time, doctors can still maintain their rights and honour? Can we seek comfort in the recently published Green Paper on Health Care Reform?

Consultation Document on Health Care Reform

          To be fair, the consultation document has made a few positive steps to achieve the purpose. These proposals, though incomplete and dotted with grey areas, ought to be taken with serious consideration instead of unconditionally discarded. Instead, both the public and the profession should make constructive criticism to make the recommendations work. Let me elaborate.

Complaint Handling Mechanism

          There is a suggestion of the setting up of a Complaint Office under the Department of Health. This Office will act as an initial investigatory body, and when there is a case to answer channel that incident to the relevant professional disciplinary body. It is a good move. For one, not all mishaps will hopefully be perceived as doctors' fault. For another, active self generating investigation can be done to catch those who want to play in the fringe of law.

          Grey areas do exist. To the public, this is a body in the Department of Health where most staff members are health care professionals. Will it still be "doctors working for doctors"? To the profession, this could be a downright attempt of the Government, of which the Department of Health is part of, stepping into the realm of professional autonomy. A more representative membership for this Complaint Office, with a proper delineation of work between it and the professional councils, using the Department of Health as a pure secretariat, could minimize the sinister perception by all.

Life Long Learning

          The Green Paper proposes that in the long term, continuing medical education should be link with registration or re-registration to practise medicine. This is a good move and must be taken on board soon, for what is there to show the public that any doctors graduating years ago are still equipped with even the basic medical advances. Life long learning must be the prerogative of any professions and trades which aim to continuously upgrade themselves. They should be proposing it to their members instead of awaiting the public and the Government to force it onto them.

Quality Assurance

          The Consultation Document rightly says that quality assurance - such as clinical audit, clinical supervision system, peer review mechanism -- must be looked into. Regrettably, there is no concrete proposals in detail. Furthermore, is the Department of Health -- the Government's executive arm to look at disease surveillance, public health education and promotion, registration and complaints, the right body to take up the role of coordinator or regulator on quality assurance for the medical profession and its specialties? Let me submit to the Government that close collaboration must be made with the Hong Kong Academy of Medicine which by statute is responsible for specialist standard, and that this body must play an active part in whatever formula used for assuring doctors' quality and clinical auditing.

Chinese Medicine

          Suggestions of the Consultation Paper are not without worries in the maintenance, if not improving medical standards. There is a suggestion to take on board Traditional Chinese Medicine into the public health care system. I would be the first to agree. Yet, the Government must be warned that to make it effective, new budget must also be allocated, lest standards of current practice will suffer if we were to thin out the already over-stretched public health care budget.

Health Care Financing

          Whilst it may well be said that fees and charges in the public hospitals are not the prerogative in considering standard of practice, yet the relationship is widely encompassing.

          The current Government policy of charging a token for any medical service irrespective of its intricacy and irrespective of the affordability of the patients has resulted in an exponential shift of patients from the private sector into the public sector. Standards are set to suffer. The infinite increasing workload of the public sector will mean less time spent by the service providers onto each patient. In the private sector, because of the lean slate, doctors will invariably be forced to cut corners, induce demand to make ends meet, affecting thus the standards and moral of practice.

          The charging policies of Government on public health service must be seriously looked at and practical proposals be made to re-balance the current imbalance if Hong Kong is moving towards a sustainable high standard of care.

Patient-Doctor Relationship

          Ladies and gentlemen, I started off by saying that health is the essence of proper and quality living. For umpteen years, to maintain good quality of health, to assure that the sick are treated in the shortest time and best way, depends heavily on a well maintained and respected patients and doctors relationship. In short, proper health care must base on mutual trust.

          The public has to be made to realize that the practice of medicine is an art for which there can never be anything absolutely right and wrong. Similarly, doctors are not born to be respected. Their respect must be earned. It would be doomsday if patients are always cynical about their doctors and doctors are forced to practice defensive medicine.

          A proper health care must be based on an amicable patient and doctor relationship. This must be the essence of any health care reform.