13 December 1998

Diagnosis of our Health Care Financing System
("Letter to Hong Kong", Radio Television Hong Kong)

(Keywords:- reform, financing, Harvard consultant, medical profession, compartmentalisation, clinical audit)

          The long awaited report on health care reform, or health care financing reform, was finally delivered -- regrettably only to the Health and Welfare Bureau and not to the public. How much of the content of the report will the public know? What portion of the content will be implemented? Will there be a health care reform or health care financing change at all? All these depend very much on the political acumen, the determination and the commitment this Government has to better the health care of the Hong Kong people.

          Let us reminisce for a moment on the background of how this report and consultancy came to being.

Finite Budget versus Unlimited Demand

          Proper health care is an essential social service that no responsible government can do without. It is on this basis that the motto of our Government, that is: "nobody should be devoid of proper care due to lack of means", must be applauded. Regrettably, without proper qualification of what "proper care" means, without regular update in governmental policy directions, this honourable statement could easily be interpreted as "anybody, irrespective of means, can get the best of care at a highly subsidised rate in our public health care service". In short, be he a pauper or a billionaire, he can enjoy the most advanced service in our public hospitals for only $68 a day and many do. More will be forthcoming, with our current economic gloom.

          Meanwhile, our population is aging requiring more chronic care. Medical technology is advancing, producing state of the art tools and treatment modalities which, though effective in offering better and more focus results, are extremely expensive. Our patients are also more demanding. All these culminate to the fact that our health care cost is rapidly expanding.

          On the other hand, public health care budget is not unlimited. The result of this finite budget to provide an almost insatiable infinite demand has led experts to warn that without a new charter, our health care cost will be unsustainable in the near future.

Government ignore need for New Policy

          Such impending crisis however is by no means new. Yet for 25 years, Hong Kong has never updated its health care policy. Even when the Chief Executive Mr Tung Chee Hwa took office, health care was never on his list of priorities to look at.

          The advent of medical mishaps, not just one but in successions, woke Hong Kong and Government up from its doldrums. Something needs to be done. And in the usual predictable government practice -- call in a consultant!

          Whilst the total report is still shroud in secrecy within the Government, bits and pieces of the Harvard consultant team are available through media reports and from the open speeches of the leader of the team. It may be timely to arouse public debate on these piecemeals to pressurise Government that health care and health financing reform are imminent if not too late!

Fragmentation of Services versus Continuity of Care

          Much emphasis has been put on the lack of efficiency of our health care system due to our compartmentisation leading to fragmentation of service. Yes, there is a Hospital Authority, a Department of Health and the private sector, but with no central coordination. A central Health Authority would thus be ideal. Yet it is deeds rather than creating another bureaucratic layer that counts.

          Frustratedly, such deeds are very much lacking. To wit, whilst the Hospital Authority is already promoting a seamless health care to enable stabilised patients to be followed up by the less costly Department of Health clinics, yet the lack of equivalent high level service in the Department of Health has become a stumbling block. Special medication needed to sustain certain diabetic patients, for example, are not available in the Department's clinics. Podiatric service for the feet, so commonly a problem with diabetic patients, are again not developed in the Department.

          Nor is the willingness of the private sector to lessen the burden of the Hospital Authority been given any facilitation. The bullock cart pace in the development of information technology in the Hospital Authority, despite the colossal budget spent, has resulted in many major hospitals still unable to dispatch simple discharge replies to referring private general practitioners. Such simple note can greatly facilitate the general practitioner to effectively share in the continuity of care.

Unfair close-shop accusation on Medical Profession

          The functioning mechanism of the medical profession in particular its registration system to practise medicine in Hong Kong and the control, or rather the lack of it, was cited extensively by the consultant team as a stumbling block factor in the development of health care service in Hong Kong. The medical profession was criticised as being self-protectionists, working in close shop favouring only the British Commonwealth nations, clinging onto the old colonial culture.

          This is downright unfair, demonstrating the consultant's lack of understanding of the local registration system. Hong Kong's registration system of doctors to practise is based on one element and one element alone -- standard -- standard that we can be accountable to the public with our hands on our hearts. Any bona fide medical graduates can come to Hong Kong to practise medicine irrespective of race, sex or creed if he /she can demonstrate the standards acceptable to Hong Kong people by taking a universal examination. Even residency status is not taken on board. Such a system is used extensively round the world. In the United States, for example, a doctor graduating in one state does not automatically give him the right to practise in another state unless he/she passes a few examination hurdles. Such a registration system based entirely on standards should never be undermined and in no way should it give way to nepotism nor political expediency!

Means to audit clinical outcome

          On the other hand, the medical profession should be open-minded to the issue that proper clinical audit is essential if we are to provide the best for the patients we serve. Yes, the Hospital Authority has introduced clinical audits in all public hospitals. Yes, the Academy of Medicine should initiate such an activity amongst its subordinated colleges for their fellows. Yet there are still a sizable medical workforce who are private practitioners and not belonging to any of the Academy's disciplines. At the same time, the profession must take a lead to exhibit our accountability to our patients. We need to put our heads together to study the need for a central body to set standards and initiate any necessary controlling actions.

Governmental procrastination major cause for flaws

          Finally, the consultant team commissioned by the Government is dead on right to point an "unmistaken" finger at the Government for lack, or should I say a complete void, of policy direction as a major cause of the flaws of our health care system. Why should such a problem be allowed to procrastinate for 25 years?

          Without sounding in any way apologetic, I feel that the underlying reasons are a few folds. As a start, health care service has been, at least superficially, satisfactory and until major crisis develop, very little pressure would be applied to the Government. Yes, there has been crisis, such as the over-heated dissatisfaction of our public hospitals by both the public and the staff in the 80s. Government's knee-jerk reaction then was to set up a Hospital Authority.

          At the same time, details of health care is very much a technical matter that the general public would not be able to comprehend.

          Perhaps in the same way that the lay public are not able to dwell onto the details of health care, the same shortcoming faces our health policy bureau in that it is run by generalists with inadequate medical and health professional knowhow. Little wonder there is a lack of wide enough vision of the relevant bureau to look at the forest instead of just individual trees in the Hong Kong health care system.

Need for altering Civil Service structure

          The current administrative structure, where civil servants are doubling up as quasi-ministers and not on a political appointment, whereby they are not directly empowered to be accountable to the public has, in my mind, cultivated much of the commonly seen bureaucratic inertia. It is not just that health is wealth, but that as Hong Kong is embarking on the road of master of our own house, our leaders must look seriously at the constitutional structure of Hong Kong and make early alteration to keep Hong Kong continuously ticking!

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