A report on two discussion forums on "Building a Healthy Tomorrow", concerning the roles of family doctors and its implications

William C W Wong 黃志威, Ben Y F Fong 方玉輝

HK Pract 2005;27:374-378

Summary

This is a report on the two forums conducted in August, which aimed at exploring the roles of family doctors and the implications of the recent discussion paper on family doctors. During the forums, the participating doctors urged the government to facilitate the development and enhance the roles of family doctors in the community. Issues on re-training of community doctors without formal higher qualifications, healthcare financing and re-arrangement of our healthcare system were openly discussed with some solutions provided.

摘要

本文是有關在八月份舉行的兩個論壇的報告。論壇目的是探討家庭醫生的角色與及最近政府所發表的諮詢文件對家庭醫生的影響。 在論壇中，參與的醫生促請政府協助發展和提高家庭醫生在社會的重要性。對其他議題包括給與未有正規較高資歷的社區醫生再培訓， 醫療融資及醫療系統重整，都有公開的討論與及提出解決方法。

Introduction

In July 2005, the Hong Kong government brought out a discussion paper ("Building a healthy tomorrow") on the future service delivery model for our health care system.¹ This discussion paper aimed to address the sustainability of current healthcare arrangement, which heavily relied on public subsidy and sought to resolve this potential 'time bomb' by realignment of the private and public services.

Many frontline doctors saw this as an opportunity for greater involvement whereas many expressed concerns. Therefore, the Hong Kong Primary Care Foundation, in collaboration with the Department of Community and Family Medicine, The Chinese University of Hong Kong (DCFM) and, Shatin and Taipo Community Doctors' Networks, organised two forums for frontline doctors on 15^th and 31^st August respectively to collect their views on the discussion paper.

Methods

Important names or representatives of various medical organisations were invited as panellists (Table 1). Invitations to frontline doctors to attend were distributed through the Hong Kong Medical Association, DCFM, the two Community Doctors' Networks and Pfizer Pharmaceutical. Thirty-two and twenty-seven doctors attended the two forums, each lasted 2 to 2 1/2 hours. Facilitated by the chairman, Dr Ben Fong, opinions and views on the discussion paper were openly discussed among the panellists and the doctors present. The forums were audio-taped and discussion transcribed verbatim, which were later analysed by using Atlas.ti (Version 5).

Data were analysed principally by the Glaser and Strauss "grounded theory" approach² and from various works on thematic analysis.^3-5 The authors started with broad headings, then identified more detailed codes before deciding on higher order headings. Some of the themes were based on descriptive codes derived directly from responses to the issues raised in the forum while others were more interpretative based on the data. The headings and codes from this analysis were combined into a list of three themes.

Results

The three themes arose from the two forums were:
1. Definition of family doctors.
2. Problems in the discussion paper perceived by the doctors attending.
3. Proposed solutions.

1. Definition of family doctors

Primary care medical force and the family doctor concept were under the spotlight in the discussion paper. The paper further attempted to define a "family doctor" as "a general practitioner, a Family Medicine specialist or any other specialist who can provide continuity of care, holistic care and preventive care".¹ Who the family doctors were and who should provide the service meant for family doctors were great concerns for the doctors who attended because of the current (or lack of) training requirement and variable quality existed across the profession.

Better quality assurance set and maintained by the government (some even suggested this should be the ONLY role of the government) was the repeated theme shared by many doctors of different background. Basic training for all new doctors before they were allowed to join the community and continuous medical education were essential measures. For those in practice, their experience should be valued; they should be provided opportunity for updating skill. Positive supportive means such as "mentoring" could be introduced.

Others expressed less concern over legislation on compulsory postgraduate training for future "family doctors" as the market demand (including the users and the medical insurance) would provide a powerful incentive. They might prefer a "bottom-up" approach whereby education was provided to the general public so that they would value the Family Medicine concept.

2. Problems in the discussion paper perceived by the doctors attending

1. Lack of trust



While the majority of the doctors agreed with the direction of future healthcare development indicated in this discussion paper, some doctors had reservation due to the previous bad experience and worried that there might be a "hidden agenda". One doctor cited the Australian example where the consultation rate was capped and hence the doctors' income. Another doctor worried the 24-hour service would be imposed upon the profession. One doctor believed that, by setting the price of outsourcing clinical work, the government could become the biggest Health Maintenance Organisations (HMO) and thereby control the market.

2. Distribution of resources



One of the major attractions of the public sector was the low fees charged to the patients. Many private doctors experienced referral of patients to the public sector would 'lose' them forever. Some doctors noted that, due to the shortage of time for consultation at government outpatient departments, repeat prescription had gone up from 4-6 weeks to 14-28 weeks. It was this unfair competition that had driven patients to the public sector.

3. Lack of the environment for continuity of care to develop



Apart from the competition from the public primary care providers and Hospital Authority, private doctors also faced competition from local pharmacy and traditional Chinese medicine (TCM) practitioners in Hong Kong. These healthcare choices, in addition to the "doctor shopping" habits and restrictions imposed by medical insurance, will make continuity of care very difficult in practice.

4. Lack of practice opportunity



A number of skills such as vaccination, endoscopy, antenatal care and birth delivery were lost due to insufficient caseload and practice as complained by one Canadian trained doctor and echoed by a few other doctors. This became a vicious cycle as the fewer the cases, the fewer the practice and the less likely a doctor would be confident to perform these procedures.

5. Range of preventive care



Preventive medicine was strongly advocated in this report but it should not be limited to disease screening (where sound evidence only existed in a few conditions) and lifestyles changes (where it was very difficult to conduct and depended on the willingness of the patients). Family doctors had largely been excluded in more important preventive measures such as vaccination, contraception and antenatal care due to the current health delivery arrangement and distribution of resources as described above.

3. Proposed solutions

1. Working together



One of the panellists reminded the doctors that the government and Hospital Authority are faced with tremendous pressure from the general public and political groups too and had to balance interests of different parties. He further urged the professionals to be fully engaged in this reform. For this to happen, both doctors and the officials should discuss openly any change in the health system as "equal partners".

2. Quality assurance



For Family Medicine to take root in Hong Kong, it had to go through a process and this process has to be planned carefully and implemented over a sufficiently long period of time. Training and standard setting should be jointly set and monitored by the profession and the government.

3. Civil rights and responsibility



For Family Medicine to flourish in Hong Kong, it had to be supported by the appropriate health policy with re-distribution and re-allocation of public resources. Campaigns and educational programmes on family doctor concept should be provided to the general public. All competing parties must have their roles carefully defined and be regulated accordingly.

4. Healthcare delivery models



There was no ideal or perfect healthcare system but one that suited the needs of society and population at large. The knowledge and skills of the family doctors in Hong Kong should be appropriately valued, utilised and rewarded. Thus, the healthcare delivery models should be arranged in such a way to reflect this. (For example, "Can family doctors be the major or even the sole providers of the childhood vaccination programme?")

Epilogue

The two forums provided an opportunity for the doctors to express their concerns and opinions over the discussion paper. The views expressed were by no means exhaustive nor representative. Due to the nature of sample collection, they merely reflected the range of opinions among individual doctors. Nevertheless, they were practical and real problems encountered at the frontline, and should be taken into serious consideration for the future reform.

Acknowledgement

The Hong Kong Primary Care Foundation would like to thank all the supporting organisations, the Hong Kong Medical Association secretariat, staff of DCFM and Union Hospital, the panellists and the doctors participating in the two forums for the assistance, organisation, financial support and the suggestions. Sincere thanks to Betty Chu from Mediaplus Asia Ltd for her painstaking preparation of the transcription for analysis.

Key messages

1. Training and standard setting should be carefully planned, implemented and monitored jointly by the government and the profession.
2. Conflicting interests must be addressed to avoid the public sector from competing with the private on unfair grounds.
3. The family doctor network should be fully utilised to provide a range of preventive care services.