30 August 1998

Healing Health Care System to boost Public Confidence
("Letter to Hong Kong", Radio Television Hong Kong)

(Keywords:- medical mishaps, reform, financing, private hospitals, criminalisation, defence medicine)

          It has been said, and proven true, that Hong Kong people are tenacious. For decades, we have faced the roller coaster behaviour of our stock market and property market, kept our cool and emerge unscathed. The same degree of tenacity, perhaps even more to be considered sometimes as foolhardy, is exhibited by our Government. For even with the gloom of economic disaster looming over our heads, our finance chiefs are still buoyant to venture statements like "we will be the first one to recover " and "we will hit them this time and hit them where it hurts".

          Yet, when it comes to health care crisis, our population becomes an easy prey and quickly lose its cool. Even our staid Government grasped at any available straw. In the recent disaster case of the Hong Kong Sanatorium and Hospital where three patients died in the dialysis set-up, our health chiefs in an unprecedented show of concern made the statement implying that the hospital's licence maybe at risk. To most, this is a jittery response to a seemingly lack of responsibility in Government's monitoring role of private hospitals. In any case, such off the cuff response does little to convince the public of Government's determination to play its expected part of assuring proper standards in private hospitals.

          The fragility of the public to health care incidences is understandable. After all, health care is an essential service that everyone will require at different times to a different degree, yet so mystified to most albeit the best of intention to communicate by the health care professionals. In short, any society, let alone Hong Kong, will need a confidence inspiriting health care system and service, for which the health care professions, not the Government, will have to lead; and the Government giving its unstinted support.

Medical mishaps cause for worry

          Regrettably, the performance of our health care services in all sectors have been far from being ideal in the last two years, with chains of blunders spreading from our public hospitals under the Hospital Authority to our general out-patient services under the Department of Health.

          It started off with blunders one after the other in our public hospitals under the Hospital Authority (HA): wrong blood transfusion, air pumped into blood vessels, milk transfused into the circulation and most recently injection of undiluted medication leading to loss of life. The blunder epidemic spreaded to our general out-patient services under the Department of Health, when mouth gargle was given as substitute for anti-fever mixture, undiluted chloroform was given for cough tonics.

          The private sector followed its wake. The last straw came when three patients died and three maimed within minutes during a relatively benign and common-a-garden dialysis treatment apparently from a contamination. Woefully, the 70-odd years of unblemished record of this private hospital was unnecessary tarnished.

          Why did all these happen? How could these be minimized let alone prevented? What penalties should the involved persons or the system be brought to bear; and most importantly, how can public confidence in our medical care system be regained?

Healing ailment in public medical system

          It would be burying our heads in the sand if we were to follow the preaching of our soothsayers that Hong Kong is just in a roll of "bad luck". Similarly, it would amount to shirking our responsibility, claiming that "these medical mishaps have happened before and it will happen again". Yes, it is true that it might well be impossible to prevent any mishaps in a setting like the Hospital Authority when there are 44 hospitals, 50,000 staff members and an average 2600 in-patients turnover everyday. Yet, each incidence, be it major or minor, could link to system problems or human errors which are preventable.

          On the issue of human error, many will point the finger at overburden in work. Rightly so. Statistics show that since Hospital Authority's establishment seven years ago, accident and emergency attendances has increased by 50%, specialist out-patient and hospital admission surged by 45%, yet the increase in recurrent expenditure was barely 30%. Such disproportion between intake and output obviously results in progressive increase in burden on the shoulder of frontline staff, for which Government policy of providing heavily subsidised treatment irrespective of affordability of the patients must be the obvious culprit. Some have called for an increase in health care spending. But when will increase be enough? Furthermore, in such economic times, it would not be surprising to witness a cut in public spending of which health care take about 14% today.

On top of its decided policy that "nobody would be denied of proper care due to lack of means", there is a dire need for Government to add that "those who can pay pay, and those who can pay more pay more"! It is a political time bomb, but it is a time bomb that Government must rally its political clout to defuse if our health care system were to see improvement.

Enhance monitoring of private hospital standards

          Turning to our private hospitals, there is hue and cry over the lack of monitoring. Yes beefing up the monitoring mechanism if we must, but the infrastructures are there for the asking!

          Let us examine the current monitoring infrastructure. First, the Government, through the Director of Health, is the licensing authority. The Hospitals, Nursing Homes and Maternity Homes Registration Ordinance empowers the Director of Health to issue licence to private hospitals. It also empowers the Director to set conditions for registration, to inspect, or to receive reports of these institutions as a monitoring mechanism. Has these been executed diligently? The Director must answer to these questions. It is the responsibility of the Director of Health to ensure that each individual private hospital meets the basic standards, both in manpower, hardware and software of health care delivery.

          Each private hospital must have its monitoring body too. Through its medical committee or similar body, it should set guidelines and audit its performance. Needless to say, such committee must not only be fair and unbiased, but seen to be so. In short, its membership should not only be the directors of the hospital alone, but outsiders be they professionals or otherwise to ensure that the auditing is made as transparent as possible.

          Let us not forget: private hospitals are very much monitored by market force. Private patients have a choice. In many ways they influence their private doctors to patronise those hospitals they feel safe. Transparency of private hospitals thus adds accountability and confidence, which such hospitals cannot do without!

No sense in criminalisation of health care professionals

          Finally, how should health care personnel be penalised if found responsible? There are those who advocate criminalisation for medical blunders. This cannot be the way forward. Any health care personnel, when embarking to provide service to a patient, must have one aim in mind -- to relieve him of his illness and suffering. It must be on this trust that a doctor-and-patient relationship is built. It is on such bondage that a doctor will go forward with his experience and knowledge to provide treatment with no constraint.

          But medicine can never guarantee a cure. Furthermore, complications can occur along the difficult path of treatment of which neither the health care personnel nor the patient expects, many of which are documented in medical literature. Furthermore, the more intricate the treatment process of the cutting edge of medicine, the higher the chances of complications. To put the patient and the health care profession in opposition partly through the imposition of criminalisation amounts to tying the health care professional's hands and putting a pressure on him before the healing process even begins. More, to the extreme, doctors may be forced to play safe in practising defence medicine, under which all sorts of testing would be taken albeit a minor ailment. All these are definitely not to the advantage of the patient.

          It must be remembered that all health care professionals are closely monitored in their professional activities by their peers through the relevant boards or councils which lay members also play a part. Any inexcusable mistake could land the professional into professional discipline which could amount to deregistration and removal of the right to practise -- a grave penalty indeed. More, there is always the channel of justice through civil litigation should a party feel aggrieved.

Building up public confidence takes effort

          Yes, to err is human. Yet we must not forget it takes much effort to build up confidence of the public towards the health care profession and the health care system; but could be destroyed by one stupid error. The repeated medical mishaps hopefully will stimulate the Government, the public hospitals and the private institutions to examine and improve the system. The health care professionals must play their part too. Our integrity and continuous self assessment is essential. After all, we as health care professionals are the hub of the health care system for which health of the society depends!

- END -