Health care reforms as I see it

P C Y Lee 李仲賢

Dear Editor,

The primary objective of government out-patient clinics (GOPDs) of the Hong Kong Government has always been for the surveillance of diseases and the control of epidemics and endemics. The curative element plays only an insignificant and secondary role, with no attempt whatsoever in providing comprehensive, whole person care, resulting in members of the public flocking to hospitals for the treatment of even the most trivial and minor of ailments. This basic government policy was the principle cause and the main contributing factor for the tremendous overcrowding in hospitals in the mid-80's leading to the creation of the Hospital Authority. There is the need to emphasise the cost-effectiveness of the "gate-keeper" role of the general practitioner in order to break this vicious circle and to prevent draining public funds endlessly.

Solutions so far offered in the current debate on Health Care Reforms concentrate on how to fund, manage or control hospital finances. The only way to contain escalating hospital costs is not to find ways and means to finance it but to cut down insatiable demands for hospital beds.

Let us examine the evidence supporting the fact that the workload of hospital physicians is under the control of general practitioners. In Australia, although less than 20% of the health care costs are paid to doctors, over 70% of all health care expenditures are determined directly or indirectly by medical practitioners, mostly general practitioners (GPs). GPs determine the number of hospital admissions, the number of diagnostic tests, the number of prescriptions and above all, the number of specialist referrals. It is the act of referral which in most cases implies a rapid escalation of costs.

In 1980 the Education Committee of the General Medical Council of England reported that due to the explosion of medical knowledge and the limited time available for the undergraduate medical curriculum, the new medical graduate has only attained a standard capable of being further trained. It implies that medical schools no longer consider it their duty to produce competent doctors on graduation, and that all new medical graduates need further vocational training.

Increasingly, new medical graduates world-wide are required to undergo vocational training in general practice before they are allowed to practise independently. In England, a doctor must have undergone at least three years postgraduate vocational training in general practice (in both hospital and community settings, but not less than one year in the community) before he is allowed to become the Principal of a medical practice. In Europe, the EEC Council of Ministers had in 1986 decreed that, by 1991, all doctors within EEC countries must undergo two years of vocational training in General Practice before taking up medical practice. Since 1973, the Australian Government had funded a "Family Medicine Programme" to train private doctors in general practice. Today, the federal budget for the training of GPs in private practice all over Australia amounted to more than Aus. $25 million (or roughly HK$125 million) per year.

This, in effect, acknowledges that the MBBS degree as a basic medical qualification is no longer considered adequate for independent medical practice. However, in Hong Kong, the vast majority of GPs in private practice and most of GOPD doctors in the public sector only possess a MBBS or basic degree. Few receive vocational or additional training after graduation, and there is no law or legislation requiring them to do so. Bearing in mind that Government had always wilfully neglected the medical needs of ambulatory patients in their GOPDs, which accounted for 15% of all out-patient attendance, and 70% of such attendance are being attended to and cared for by the few thousand non-vocationally trained GPs in the private sector, small wonder that the Hong Kong public are obliged to turn to hospitals for treatment.

In the "good old days", though recognised as being excellent centres of medical care, government hospitals did not provide much in physical or "animal" comforts. To enjoy "hotel-type" accommodation in addition to medical attention, members of the general public have to patronise private hospitals which charge exceedingly high fees. With the advent of the Hospital Authority, public hospitals were completely refurbished and nowadays some are even more comfortable and better furnished than private hospitals, and cost next to nothing. The public now flock to public hospitals, resulting in most private hospitals being in financial difficulties. Under the circumstances, the system creates a vicious circle feeding upon itself, and rapidly becomes unsustainable financially and economically. No amount of financial juggling or means of funding or sourcing, etc., can break the vicious circle unless something very fundamental is done.

The first and obvious task is to find ways to entice citizens away from hospitals to be treated by well-trained GPs in the community. This can only be accomplished by Government taking the lead in training front-line doctors on a massive scale, matched with extensive communitywide publicity. Once the standard of medical practice of front-line doctors (both private and GOPD doctors) have been raised, the public will respond accordingly because it is so much more convenient and affordable. This is the first step towards converting the Health Delivery System from that of "hospital-based" to "community-based".

The Government is therefore urged to adopt the following recommendations:

1. The Government, possibly in collaboration with the Hong Kong College of Family Physicians, should establish as soon as possible a "Family Medicine Programme for Practising GPs" along the lines of the Australian model, the UK "Vocational Training Programme" of the National Health Service and other similar institutions, to up-grade the standard of medical practice of all our front-line doctors.
2. Legislation should be enacted to require all doctors, in addition to the existing compulsory one-year internship, to undergo a further two-year vocational training before being granted a licence to practise independently. In this respect, I recommend a long "grace period" of five or more years to allow practising doctors to adjust, adapt and be integrated into the new scheme of things.
3. When the requirements of the above legislation are fully implemented (which is expected to take anything from five to ten or more years), Hong Kong would be in a privileged position to emulate the UK practice of disallowing patients to have direct assess to specialists, who can only see referred cases. This simple requirement will drastically reduce health costs.
4. The object of the legislation should not only be to raise the standard of medical practice, but also to ensure that such standards be maintained at an appropriate level. This can easily be done by emulating the present-day regulation of renewal of licenses for specialist practices in the Medical Registry by requiring all doctors to provide proof of continuing medical education (CME) before practice licenses are renewed.

This paper does not call for all doctors to become Specialists in Family Medicine. The aim is to ensure that our front-line doctors, the GPs in both the private and public sectors, have adequate knowledge and training in the discipline of family medicine to provide competent and holistic medical service to the general public as a means to induce the man-in-the-street to have faith in being treated in the community as out-patients instead of only in hospitals as in-patients. I am fully convinced that the "lasting cure" for Hong Kong's health care problems can only be achieved by the integration of our health care system and the training of our front-line doctors. One glaring example is England, where for the last 20 years a great number of hospitals had been closed down because of the tremendous drop in the demand for hospital beds.

I wish to conclude by recording herein an interesting but true anecdote. It was in the early days of Chris Patton's governorship when the Honourable Virginia Bottomley, the then UK Minister of State for Health, visited Hong Kong. I sat next to her at the dinner given in her honour in Government House and the conversation naturally turned to local health problems. When I told her that the Hong Kong Government intended to build 6,000 hospital beds all over the territory in the next few years, she turned to Chris Patton to ask, "Is that true?" When Patton replied in the affirmative, she exclaimed, "And I am going back to England tomorrow to close down 14 hospitals!!"

This conversation took place over 10 years ago, but it clearly demonstrated what is critically wrong with the health delivery system in Hong Kong – then and now!!