Hong Kong Sanatorium & Hospital

Li Shu Fan Lecture

“Private Hospital Services: Past, Present and Future –

A Tribute to Dr. Li Shu Fan”

Speech delivered by Dr. C.H. Leong

19 May 2012

      To be invited to deliver a named oration is an hounour. To be invited to be the First Orator is a distinct honour. To be invited to deliver an oration named after a distinguished person that the orator respects and revered is an honour and an “offer that cannot be refused” to paraphrase from Mario Puzo’s “the GODFATHER”.

      It is on this background that I accepted to be the first Li Shu Fan orator, at a time Dr. Li’s Hospital, the HK Sanatorium & Hospital celebrates its 90th anniversary. Let me therefore thank Dr. Walton Li and the Board of the Hospital for the invitation.

The name Li Shu Fan is no stranger to anyone who has any claim to be a HK belonger and to many in the international medical world. Prof. Felix Marti-Ibanez, a former Chairman of the Department of the Academy of Medicine New York Medical College once wrote:

“Li Shu Fan had a fabulous career. His beginnings are told with the full flavour of old China. His careers are numerous – a surgeon, a hospital builder and administrator, a statesman and a counselor of statesman… a war refugee from the Japanese, a compatriot and physician of Sun Yat Sen… a protector of the poor and unfortunates…”

Closer to home, when Dr. Li was conferred the Honorary Doctor of Laws by the University of HK at its Jubilee Congregation on March 16 1961, the public orator gave a citation that in essence highlighted Dr. Li’s five big achievements. Liken to a rhinoceros, Dr. Li had an energy and tenacity to organize health care services in Kwangtung Province, under the new China as Minister of Public Health. Later in HK as member of the Sanitation and Medical Board, Urban Council and Hygiene Council.

Liken to a buffalo, he is hard to kill as he triumph over a revolution, the 2nd World War, diphtheria, TB and even accidental self-inoculation of bubonic plague.

Liken to a leopard that never changes its spots, as a doctor, Dr. Li abide religiously to the Hippocrates Oath.

Liken to the lion as a king of beast, Dr. Li is a king of gestures in his numerous contributions and devotions to education and the University of Hong Kong.

Most importantly, of elephantine proportion is his achievement as Chairman of the Board of Directors of the HK Sanatorium- for 35 years – the only private hospital that provide training for nurses and midwives.”

It is therefore befitting that I should dedicate his first oration to “Private Hospital Services and Practices, the past, the present and the future in HK” to pay tribute to this great man.

For myself, having been engaged in private medical practice, mainly in private hospitals, for over 30 years after some 16 years of services in public hospitals, I would like to take you through my thoughts the following areas:

- Some facts and fancy of Private Hospitals;
- The Role of Private Hospitals in the health care services and the changing landscape;
- Private Hospitals… Private Practitioners… and Private patients; and
- The Future of Private Hospitals; Private Hospital Practices in Hong Kong.

Facts and Fancy
Hong Kong has the benefit of a dual health care system – a public system that is financed by the tax payers and act as a total safety net, and a private system which provide services for a fee. Similarly, we have public and private hospital services along the same line.

Statistics have revealed that there are currently 39 public hospitals with 27,041 beds under the purview of the Hospital Authority and 13 Private Hospitals with approximately 4,098 beds. The public service cater to serve 92-97% of the patients who needed hospital care. This percentage varies and fluctuates with the general economy, availability of hospital beds and situations of crisis. In time of plenty, many will flock to private hospitals where there is a choice in services with shorter waiting time. In time of lean, the pendulant will swing the other way because of the unaffordable charges of private hospitals.

Because private hospitals are enterprises operating like a business, they very seldom turn patients away. Paradoxically, they did turn patients away in two periods in the recent 20 years – in 2003 and early 2004 during the SARS saga, when private hospitals did not have the facilities to cater for possible SARS patients for lack of isolation facilities; and today, patients are turned away because private hospitals are constantly filled to the brim. Often times, reverse referral takes place, emergencies patronizing private hospitals are referred to public hospitals.

      For the non-medical audiences, you might be amazed by some peculiar admission patterns of HK’s private hospitals. Patients avoid admission to hospitals and non emergence surgeries during the months of May to July – parents need to stay at home and be vigilant to coach and to ensure their offsprings will study unperturbed for the term end exams. Similarly, non emergency surgeries are commonly avoided around major festivals, in particular Ching Ming and Chung Yeung for superstitious reasons.

      A while ago, I mentioned that there are currently only 13 private hospitals. Interesting enough, only 2 of these were established after the 1990 – the Union Hospital in 1994 and the Anti Cancer Society Nam Long Hospital in 2010. It would be wrong to say that there are no interests to develop private hospitals, after all HK has always pride itself to be a medical hub of SE Asia.   Two other hospital projects did actually emerged after the 1980 - a major comprehensive project in the 賽西湖 area - 華人醫院which unfortunately failed to materialized, and a hospital - the “Re treat” which did open in Clear Water Bay area but closed down after a short period of time.

Is the law over stringent to deter any interest in building and operating private hospitals? This is obviously Not the case. Cap 165 of the HK Laws, “Hospitals, Nursing Home and Maternity Home Ordinance” depicts that anyone, any organization with substantial connections with the medical profession could apply to establish private hospitals. Furthermore, regulating private hospitals are fairly generally encompassing consisting of “The Director may by regulation provide for (a) records to by kept of patients received into a hospital …, and (b) notification to be given of any death occurring in hospital ….” (In short all hospitals need to report who was admitted and who died.)

In fact the control, the regulation of private hospital under the ambit of the Dept. of Health was considered for a long time to be almost non existent until an accident occurred in 1998 where there were unfortunate mortalities and morbidities in a Hemodialysis unit. That the government then woke up to the need to impose more stringent monitoring to private hospitals, spearheading the introduction of the “Code of Practice for Private Hospitals”.

Why then when hotels, shopping malls and even elderly homes were mushrooming yet private hospitals did not follow in the wake?

I believe that there are a few reasons. Firstly HK has shortage of land, and any land sale is extremely expensive. Any project developer should they ever acquire a piece of land would rather transform it into real estate which give quicker and higher returns often well before the property is even built. Developing a private hospital is a long term investment with a lot of unpredictable. Most executive of existing private hospitals will tell you that they need a consistent 70% occupancy before breaking even. A hospital after all is not just a hotel providing comfortable hospitality service, it is also a place to cater, on one hand for the healthy when they need body check up, and on the other to treating the very sick, many of these service are extremely costly to say the least.

Even when a piece of land is identified and the developer is willing to invest, the plan has to be submitted to the Town Planning Board for possibly rezoning after which, and in today’s political climate, scrutinized and bashed by the district inhabitants and councilors - yes, a hospital is good but not in my backyard” they will say.

Furthermore, government may impose requirements such as the need to contribute a certain percentage of the beds to public use when the needs arise. Any developers, any financer would therefore think twice before considering entering the fray.

The squalae is that since the 1990s only 2 private hospitals had been developed that are still functioning - the Union Hospital which has taken years to break even, and the Nam Long Hospital which came out of the Hospital Authority wings in 2010, but its future is still very much on a balance.

Incidentally, most of the 13 private hospitals in HK are non profit organizations managed by boards consisting of philanthropies or religious organizations answering to the call of the public, they are in essence “Profit Making but not Profit taking” -

Profits from patient services are plough back into the hospital for development. At the HK Sanatorium for example, the net income from the Hospital is plough back to support the development of the hospital and to partake charitable works through - the Li Shu Fan Medical Foundation - to support education for staffs, especially nurses, and to subsidize needy patients that require special services. An example is when a needy patient is subjected to kidney transplantation and I am quoting some of my own patients, he only pay a token sum while the Foundation supports the rest provided that the teams of doctors in charge waive their professional fees.

The changing Role of Private Hospital in HK
Most private hospital began on a general concept and aim to provide an alternate place of treatment of illness that offers some degree of luxury and comfort, more personalized care, choice of service providers and choice of time for treatment that public hospitals were not able to provide. They aimed to serve patients who have basic, simple, less complicated conditions while high risks patients with complicated conditions were referred back to the public hospitals.

The reasons are obvious:

There was then a lack of expertize in the private settings;
The staffs were NOT trained to take up complicated conditions; and
It might be too expensive for complicated cases requiring longer term management in private hospitals.

In the 50’s and 60’s for example, a typical operation list of private hospitals would consists of appendectomies, galls bladders removal, and at most a simple stomach operation usually on less risky patients. To wit, HK Sanatorium was established in 1922 as a Sanatorium.

The first change came in the late 70’s when more and more doctors who have gained training and exposures overseas returned to HK. They are not accustomed to the bureaucracy of public hospitals, at the same time because of the fairly low pay, they joined the private market. Armed with the passion and the expertise, these trained specialists started to introduce more state of the art treatment into private hospitals. Seeing the business benefits of such new services and facing the demands of these young new specialists - remembering private medical services then was still very much a “doctors’” market - most private hospitals complied and upgraded their facilities. It may be worthwhile to note that the first CT scanner was installed in a private hospital. It was only after the then governor of HK who was suspected to have a stroke and had to suffer the humiliation of dong a CT brain, not in his public medical service, but in a private setting that the then government woke up to the need for a public CT scanner.

The next major change came to private hospitals in the 1990s after the establishment of the Hospital Authority. Hitherto when public hospitals were under the purview of the then Medical and Health Department, public hospital services were the centre of daily media ridicule - waiting lists were long, camp beds all the way into toilets was the rule rather than the exception. Petty corruptions exist – “pay a tip or you would not get a bed pan”.

When Sir S Y Chung, the then Chairman of the Provisional Hospital Authority was asked how confident he was that HA will improve the situation, he said “ the public hospital services cannot be worse any change can only be better” The HA was established in 1990 to improve public hospital management. Overnight, situation improved, patients started to flock back to the public service to the extent that the HA became “a victim of its own success”.

Private hospitals which before had been complacent because there had never been a real competition from the public sector, sudden dawned that they were losing their attractions. With no hesitation, they move to upgrade themselves - refurbishments, improving facilities, improve hospitality, modern and newer machines were purchased at the drop of the hat. Overnight, they all turned into major comprehensive hospitals taking on major surgical procedures, transplantations, scientific reproductive technologies, ICU care, etc, all to the benefits and comfort of patients and improve performance of health care workers. But alas, the price also soared into the realm of 6 stars hotels and beyond, or so they all claimed.

It may be of interest to Dr. Walton Li that some of the guests tonight told me they are NOT interested at my lecture. They came for the dinner - to recover loss grounds, having paid so much to the HK Sanatorium as patients in the last few years. Today sky is the limit in charges.

Joking aside, at the risk of being accused of defending private hospital and private hospital practice as I am a private practitioner, having worked at both public and private sectors for a considerable period of time, I have to admit that personalized service in the private hospitals are something that the public sector will find great difficulties to match. The benefit of bondage & trust between patients to hospitals, patients to private practitioners, patients to private hospital staff goes far beyond the effect of treatment. Perhaps this is because patients choose their doctors, perhaps health care staff could spend more time with the patients.

Incidentally many private doctors do cut down their fees voluntarily when facing a patient with economic problems. Similarly the other health care staff would do their best to help patients contain their cost.

The Changing Relationships between Private Hospitals and Private Practitioners and Private Patients
It has to be true to say “a hospital cannot do without doctors”, similar doctors will also tell you that “doctors’ could not do without hospitals”. Some form of relationship or symbiosis obviously must exist.

To non medical personal in the audience perhaps, I would like to spend a few minutes to expand on this relationship. Almost all private hospital have 2 categories of doctors – “IN house doctors” and “ Honourary Consultants”

“In house doctors” are direct employees of the hospital, In bygone years, in house staff look after the outpatient services and act as covers or standing INS for emergencies when the Honourary Consultants in charge of those patients could not be contacted or before those consultants arrive onto the patients bedsides.

Honourary Consultant on the other hand, has no direct relationship with the hospitals. They are given admission rights to admit patients to that hospital and utilize the hospital’s medical facilities. What they do for the patients, what type of treatment is being ordered, how much is the fee, are all matters between the Hon Consultants and their patients of which the hospital plays no part nor control. Obviously the hospital charges for the rooms and services facilities. In short, the Hon Consultants bring in the patients (or in the commercial sense – the business) and the hospital gain benefit from providing the facilities.

In those bygone years where the pool of private practicing specialists were small, the situation was a “doctors’ market”. Most private hospitals would bend backwards to get into the “famous” private practitioners “good books.”

With the advent of specialist registration of doctors, with the political scene that demanded accountability and with the government introducing a code of practice for private hospitals, private hospitals woke up to the fact that their responsibilities were up to change. Yes, the Hon consultant who admit a patient is still totally responsible for that patient, yet the hospital could not absolve itself from blame when problems arose. Hospitals could be accused of granting admission rights and treatment privileges to inadequately qualified doctors, similar hospitals could be criticized of having no means nor even yardsticks to regulate let alone monitor those doctors’ performances. Overnight, hospitals tighten up their “admission privilege” criteria, specialist registration was used as a yardstick and facilities of treatment were granted only to doctors who had track records of such training and experiences. A code of practice for doctors was also imposed.

With more and more private specialists and relatively less and less private hospital beds, the situation is now reversed. Today, it is the “Hospitals’ market” and private hospitals call the “shot”, not the doctors anymore.

While such a change may be to the dismay of many a private practitioner, it may well be a blessing to the patients in a subtle way. Doctors are now being regulated and monitored - standard could be assured. Many private hospitals too conduct regular: “Morbidity and Mortality”, “Audit” meetings to analysis treatment complaints and possible medical mishaps, keeping all doctors vigilant of their performance.

Just now I mentioned that most private hospitals started off with Honourary Consultant bringing in patients. In essence, while the hospital collect fee from utilization of provided facilities, they do not have a share of the doctors’ charges. Meanwhile sizable budgets are being spent on more and new facilities and to continuously upgrading equipment. Somehow the hospitals felt that while the consultants’ income are thus optimized, the hospitals are not getting back their fair share. Private hospitals therefore started to introduce a third category of doctors – “in house consultants”. While not strictly employees, these in house consultants are offered varying terms including the setting up of their practice in or by the hospital, perhaps even a straight salary. In turn their income from treating patients will have to be shared with the hospital. It is a commercial secret, but I would imaging different doctors would be offered different contracts. Patients turning up at out patient services requiring specialist care without prearrangement with a named Hon consultant will be channel to these in house consultants. To the young doctors joining the private market, this is a distinct advantage – they do not need to bear the burden of setting up their own practice and though relatively unknown, they will not be short of work, being adequately supplied from the pool of dropped in patients to the hospitals.

How do all these affect the relationship between private patients, private consultants and private hospitals. In the “old system”, all patients were admitted under the care of consultants of their choice, a patient thus “belong” to that consultant. Today patients are admitted to an quasi-employee of the hospital, perhaps not out of their choices, they in essence “belong” to the hospital.

Let me hasten to add that I am in no way implying that standards of care nor effectiveness in treatment are in any way affected. Yet the time honoured benefit of private practice where there is a complete freedom of choice of doctors is to a certain extent tainted.

However, in the long run, patient could subtly be benefited. As hospitals engaged more and more employee consultants of different specialties, the move will be to form “specialty departments”. With departments formed, services could and will be more structured, standards better controlled, charges more streamlined. Gone will be the days where Hon Consultant could “shoot from the hips”, they will have to eat the humble pie that they will be progressively regulated and monitored by the respective departments and the “Department Heads”. Needless to say, I personally belong to this category. Yet, this has to be the way to go.

The Future of Private Hospitals and Private Hospital Services
Let us look at some basic factors that could affect private hospitals functions; and their directions in the future.

The government’s new policy on requirements for future private hospitals;
Government’s push for a Voluntary Health Insurance Scheme (Health Protection Scheme) as a means of retaining public private services balance;
Medical service as one of the enterprise for HK’s economy in the future; and
Private Hospitals extending their role beyond hospital patient care.

Government new policy on Private Hospitals
Let me elaborate, while in the past, the way government oversees private hospitals was considered more as a show rather than a reality. The recent tendering requirements as stipulated in the 2 pieces of land designated for private hospitals in Wong Chuk Hang & Tai Po showed that government has changed its attitude and now means business. Performance pledge is the main requirement for tendering criteria and land premium only comes a small second (performance 70%, land premium 30%) In short, any tenderer will be requested to submit 2 tender envelopes – performance and land premium. The performance criteria is considered first, and it is only when a tenderer is considered to have fulfilled the required performance then the envelope on land premium is taken on board.

Let me illustrate from excepts on charges and services arrangements in the tendering requirement:

For Service Arrangement:

More than 50% of the inpatient bed days taken up in the Hospital each services year must be for service provided for “Eligible Persons” i.e. Hong Kong permanent residents.
For obstetric service – The maximum percentage of number of obstetric beds throughout the term must not exceed at all times 20% of the total number of hospital beds being provided by the hospital.

For charging arrangement:

At least 30% of the in-patient bed days taken up in the Hospital each service year must be for services provided through standard beds at packaged charge for Eligible Persons.
Packaged charge must cover doctors' fees, maintenance fees, diagnostic procedures, surgical operations, laboratory testing, X-ray tests, drugs, and other miscellaneous items;

Let me sound a word of advice, for while these requirement are served to new hospitals, there is nothing to stop government from slowly turn the screws and impose new and similar regulations on existing private hospitals, e.g. when they submit plans for redevelopment or expansion - all in the name for the betterment of the public.

I could be accused of preaching to the converted if I were to state that HK has probably the best public health care system, in that it provide the best of available treatment for all, irrespective of means, race, sex, age, religion or political believes. Yet, we also know that this system of “catering for an unlimited demand and needs using a limited budget” could not be sustained unless there is a proper balance of utilization of public and private hospitals.

How do you entice the general public, especially the middle class, the more educated, the better informed and perhaps the more affordable, to voluntarily utilize private hospital services besides giving them better physical environments? I believe there are 4 criteria:

By providing effective monitoring of private hospital by a relevant authority;
By developing a better structured patient service through team work, especially when crisis set in;
By ensuring that charges are affordable and transparent; and
By offering genuine free choice of medical service by their ideal service providers.

It used to lament that private hospitals are 無皇管. I believe government is doing its best to recover loss ground on this criticism. To wit, there are:

More efficient and effective monitoring through more onsite schedule and unannounced visits and an introduction of a “code of practice” which private hospitals are required to abide;
Compulsory reporting of “medical incidence or mishaps ” within a determined period of time; and
Stricter terms in issuing of license for new hospitals based on performance pledges.

To be fair private hospitals are doing their share too to further enhance the public’s confidence.

Stricter criteria on granting admission rights to doctors base on qualifications and training and experiences;
The development of “specialty departments” in hospital to determine performance and performance pledges by all medical personals;
Monitoring of doctors performance through mortality and morbidity analysis and clinical audits and issuing advices and warnings to doctors with substandard practices.
Offering themselves (the hospitals) to be assessed by international accreditation bodies.

The Voluntary Insurance Scheme (Health Protection Scheme)
A healthy health care service, a sustainable health care system of high standards cannot depend on tax payers or public purse money alone. It is on this basis that for some 30 years, HK have been searching for a health care funding formula which could work and stimulate the least opposition from the public.

Facing repeated unsuccessful attempts, two years ago, government decided to promote a “Voluntary Health Care Insurance” Health Protection Scheme with the following characteristics:

There will be package deals for common treatment procedures;
Private hospital must allot a certain percentage of beds to these package deals.

For the first time too, government is imposing regulations over the insurance industry. Gone will be the days when insurance institutions could say NO to people over 65, and to those with known chronic illnesses, be they a subscriber of existing insurance policies or new applicants, albeit with a higher premium, threatening that government stands ready to take over.

An authority by statute is being proposed to oversee the whole scheme, and an initial financial injection of $50 Billion is put in reserve to support this scheme.

Government appeared determined, to make private hospital services affordable, but will it works?

As a health care professional myself albeit a senile one, I hasten to sound a word of warning, package deals are good in controlling cost to the advantage of the patients. Often times too, it is a mean to educate the service providers a sense of cost effectiveness and cost efficiency. Yet, in the process of managing a patient, one often face multiple variables even from changes in the patient’s physical states when the services providers may have to change course in the proposed treatment e.g. requests for extra investigations over and above the package deal. How should one proceed? The best for a patient’s well being must never give way to financial consideration nor administration expediency. We must not allow the ghost of Health Maintenance Organization (HMO) to haunt the revered health care system of HK!

Health care as an economy pillar
In his policy address in 2009-2010, the Chief Executive Mr. Donald Tsang stressed that HK’s economy in the future should not be based only on land sales and as a financial centre. Rather, we should develop new economic directions.

Health care services were chosen for possible development into an industry to drive our economy.

For many years, the patronage of HK’s private and public hospitals is like a see saw. When the economy is good, patients move from the public to the private sector. When the economy faces difficulties, it is vice versa. Improving private services, better control of private hospitals will no doubt ease the private publics’ imbalance cutting down the public load. Yet as such, there is little to booster HK’s economy. It is money transferring from one pocket to the other. To be an “engine for economy development, we must attract “foreign” or “outside” capital through our private medical services. I believe today is an opportune time. Firstly, we have the world’s recognized expertise. Secondly, we are looking at 1.3 billion compatriots from the Mainland, many nouveau rich attracted by HK’s Health brand name, be it for major surgical procedures or for just body check ups. Thirdly, herbals medicine, herbal therapies, herbal rehabilitation and even herbal rejuvenations are the fashion on health today, and herbal medicine originated from China, HK could therefore well be a centre for “Herbal Health Farm”. One principle however has to remain unperturbed, all our private hospitals must realize they have social responsibilities in that the care HK people must take precedent.

Extending the Role beyond Hospital Patient Care
Private Hospital as Training, Teaching and Research
      It is erroneous to believe that teaching of medical students, training of medical personal could only take place in public hospitals. The very much sought after teaching hospitals in U.S. are private – Mayo Clinic, Cleveland Clinic, etc. HK Sanatorium has been a centre for nursing training almost as early as its inception.

      Today private hospitals should capture 3 advantages pertaining to becoming a training centre – Firstly, there are now increasing numbers of recognized specialist trainers in the private hospitals having left public services. Secondly, there could be increase in teaching material with more private patients when the Health Protection Scheme materialized. Thirdly, private hospitals are more flexible in investing in modern and up to date equipment and technologies. All these will enhance teaching and training and research. For years, the HK Sanatorium has cooperated with HKU for training medical students and junior medical staffs. This should be expanded. I call upon the Academy of Medicine and the relevant Academy Colleges too to assist the different “specialty departments” of private hospitals to be accredited as training centres to enlarge our specialists training pool.

Private Hospital extending into the Community
Hospitals today should have “no walls” and patient care should extend beyond the confinement of the wards of hospitals. This is what “Holistic Care”, “patient centre care” is all about.

The Baptist Hospital has developed a one stop service for the elderlies of the community. Any elderly admitted will be thoroughly assessed to be prepared for management in the community when he/she is discharged. This will cut short the hospital stay and assist the elderlies to remain the community and their own living environment that will benefit and hasten total recuperation from their illness.

Similar and comparable community care should be developed by all private hospitals in the future.

What then is the future for private hospitals and should investors commit themselves to develop private health care?

I mentioned at the very beginning that any private hospital in essence is an enterprise – a business. As a business rightly so, it must be profitable. On the other hand, all business are encouraged to have social responsibilities, especially so in the health care sector. Profit is important, but it should never by the sole consideration.

I am in no position to advise. Instead, I have listed out the challenges, the problems and the opportunities, so that related investors could make informed decisions.

One would have to assume that future private hospitals will have to face stricter monitoring, tighter control and wide encompassing accountability from government. Do not forget too that there will be more stringent monitoring by the public. To wit, in one private hospital, the number of complaints in the last 12 months amount to over 100. Yes, many of these are frivolous, but they need to be addressed.

I would envisaged that there should not be any lack of patronage, instead, there might be many more who will be seeking private hospital care – improve private hospital services and transparency of charges, the enlarging middle class. The promulgation of the Voluntary Insurance Scheme (HPS) too will boost the patient inflow, for many will be made affordable to private hospital services through that insurance scheme.

I believe that operators should think “out of the box”, there are many functions that private hospitals could partake on top of the “traditional” ways of patient care through which the hospitals could gain mileage. Involve in teaching, associated with a University medical school will for example elevate their Brand Name making the hospital more attractive.

Yes, there could be a curb on profit, but there are other compensatory advantages.

I was also asked that with the imminent changes of government, will there be any major policy alterations. I do not have a crystal ball and there are a few in the audience who are more appropriate or authoritative to give you that answer.

      Be that as it may, I believe that private hospitals have come and it must stay. HK’s health system stands tall as the pride of the world because of our dual system – the public services providing the safety net and the private, the satisfaction of choice. Countries who practice “socialize medicine” have failed to provide acceptable care for their citizens.

      In Canada for example, Canadian go across the border to the U.S. to seek private care frustrated by the laissez-faire attitude of staff - a product of socialize medicine. On the other hand in the U.S. where health care is predominantly private, it is a shame that despite being one for the most affluent countries of the World, millions of U.S. citizens do not get adequate health care coverage.

The future of HK health care therefore depends on a proper balance between the private and the public.

In the last 40 minutes or so, I have attempted to elaborate to you some of the structural and operational ways that government and the private sector are and will be trying to achieve private/public balance.

This however is not enough.

The key issue is on policy decision. Government must decide “what is the high standard and highly subsidized public health care for and for whom?” and how should the health care budget be apportioned to the citizens. Yes, all HK citizens have a right of access to public health care but should all be subsidized in the same level irrespective of means and severity of illness? I personally have always promoted the concept of “Target Subsidy” where the level of subsidy is targeted to the need. I fervently believe that public money should be spent on those and those conditions that needed it most. This is the only way that public health care could be delivered efficiently its defined role as a safe net and private hospitals assured their rightful positions.

All these needs political clout and political determination.

Hon Guest, Ladies and Gentlemen, when Dr. Li Shu fan founded the Hong Kong Sanatorium and the Li Shu Fan Medical Foundation his philosophical conviction was “to leave the world a little richer then I found it”. Dr Li’s conviction has bear fruit. The health care service in Hong Kong be it private or public has advanced so much since 1922 when the Hong Kong Sanatorium was built, all for the benefit of the people.

I would like to end my paying tributes to Dr. Li again by using the words from Dr. Edward Patterson, a pastor, a hospital administrate and a revered surgeon of Nethersole fame “We have noted the contributions written in life blood, by devoted men and women who spared nothing to bring healing to such people, a deep healing that has been built with the very spirit of Hong Kong”

Dr. Li is the shining example.

Thank you.