12 December 1998

Never too late to address weaknesses of our health care system

(Keywords:- HMO, quality audit, private sector)

          There were days when the words and actions of  doctors were al supremo. Yet, with the development of an open society; with the advent of citizens and patients rights; with litigations at the drop of the hat, the days when doctors are demi-gods are gone.

          This is a good thing for like every profession and trade, the medical profession have to be accountable to what they do -- accountable to the patients they serve, and accountable to the peers of their profession. Accountability also means better rapport with their patients, and accountability will keep them on toes to do things properly and in keeping with the cutting edge of medical advancements.

          Amongst all these, however, two principles in medical practice should never be undermined.

          Whilst medicine is a science, the practice of medicine is an art. In short, there is the element of previous experience, previous examples, gut feeling or sixth sense that prevails. It is something that is between the doctors and patients for total understanding. That is what the time honoured doctor-patient relationship is all about.

          Secondly, there is the all important concept of professional autonomy. The standard of practice of a profession must be the prerogative of peer assessment based on standards -- standards which are derived from collective decisions determined by experiences locally and internationally and evidence-based medicine. In the delivery of care, the doctor in charge must be the one who knows best. He formulates the treatment procedures with his patient, who has the right to choose for other options.

          Any interference by the state, the government, on what to treat and in particular how to treat violate the autonomy and will not be in the patientsˇ¦ best interest.

          Take the recent controversy on liver transplant. The law is to prohibit organ sale. This all parties fully accept. Yet, when a transplant was not allowed to proceed simply because a consent form for operation was not signed in compliance with the law and the patient was in coma, controversy abounds. Without pre-empting, there is a problem of how much the law could or should override professional autonomy and judgment, when a life is at stake.

          The worse scenario would be when a profiteering middle-man steps in between the patient and the profession. Under the disguise of managed care, the middle-man controls how to treat, what to treat and what to give for treatment basing on the lowest cost so that he can get the highest gain. The patients suffer, the doctors left dejected, the doctor-patient relationship shattered, and the health maintenance organisationsˇ¦ executives get away with the profit.

          Whilst Hong Kong has much strength in health care, we have also many weaknesses. One weakness is that it is fragmented, compartmentalised and lacking  rapport between the public and private sectors. It is time for reform, if it is not already too late. The fact remains that Government has not taken the initiative of introducing or formulating up-to-date health care policies for a quarter of a century.

          Another area of weakness is that there is no audit of outcome of care. The Hospital Authority has started to do this, but a lot of work has yet to be done by our private counterparts. Yes, the private hospitals can come up with self assessing medical committees. The market force will also regulate. Yet, our patients may not be that well informed or knowledgeable to make the distinction.

          Doctors must be accountable for what they do --  accountable not just to the patients, accountable not just to their peers, but accountable too to the health care system and the society. There is thus a dire need to set up some forms of a total outcome care audit. Should this be done by a body from the profession or in association with the consumers and government? This must be debated and yet it must be the way forward.

(Hongkong Standard)