March 2008, Vol 30, No. 1 |
Original Articles
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What sort of Primary Healthcare Service does the Public want?Research Committee, The Hong Kong College of Family Physicians HK Pract 2008;30:24-28 Summary Objective:To obtain a picture of the public's perception of primary healthcare and their expectations of related services. Design: A questionnaire was developed with telephone interview conducted by the Social Sciences Research Centre, The University of Hong Kong. Subjects: Eligible respondents were residents of Hong Kong and aged 21 years or above and all were Cantonese or Putonghua speakers. Main outcome measures: The type of primary care service that the public wants, factors affecting the public's choice of primary care service; knowledge and perceptions of the concept of family medicine and family doctor. Results: Nearly 65% of respondents obtained their primary healthcare services in the private sector. 58.7% preferred seeing the same doctor for their illnesses. 56.2% have a regular family doctor. 72.8% agreed that primary care doctors should receive formal family medicine training. 54.2% agreed that a family doctor with formal training was a specialist in his own right. 87% agreed that a family doctor could provide a detailed explanation of their medical conditions. 88.6% agreed that the family doctor should discuss the content and reasons for his recommended management decisions. 81.5% thought that they could ask the family doctor for advice on lifestyle. 75.5% agreed that primary care doctors should provide preventive care and cancer screening. 64% agreed that they would pay for these services. 89.3% agreed that their primary care doctors should have access to their records in the government hospitals. Conclusion: The private sector provides the majority of primary healthcare. The community prefers their doctors to have some formal training in family medicine and they consider a formally trained family physician is a specialist in his own right. Consistent with this thinking these patients have sophisticated expectations for those who are trained as family doctor specialists. The implication of this survey is that the community would welcome more resources to channel into family medicine training and the development of a better public-private interface mechanism Keywords: primary healthcare, family doctor, training 摘要 目的：了解大眾對基層醫療的認知和期望。 設計 : 由香港大學社會科學研究中心統籌，以電話採訪形式進行問卷調查。 對象：年齡二十一歲或以上能說廣東話或普通話的香港居民。 主要測量內容：大眾想要基層醫療的種類，影響他們選擇的因素，對家庭醫學和家庭醫生的認知。 結果：約65%的受訪者使用私家基層醫療服務。58.7%選擇看同一個醫生。56.2%有常看的醫生。72.8%同意基層醫生應該接受正統的家庭醫學訓練，54.2%認同有正統訓練的基層醫生是專科醫生。87%認為家庭醫生應詳細地解釋他們的病情，88.6%同意家庭醫生應就治療的內容和原因給予足夠的討論，81.5%覺得他們可向家庭醫生詢問健康的生活方式，75.5%同意基層醫生應提供預防性治療和癌症篩查服務，64%同意為此付款。89.3%同意家庭醫生可使用他們在醫院的病歷。 結論：私營部門提供大部份的基層醫療服務。大眾期望基層醫生有正統的家庭醫學訓練，他們亦認同正統受訓的家庭醫生是專科醫生，與此同時，他們對家庭醫學專科醫生也有較高的要求。本考察指出社會接受多投放些資源做家庭醫學訓練，建立一個更好的公私營協作醫療服務機制。 主要詞彙：基層醫療，家庭醫生，訓練。 Introduction In July 2005, the Health and Medical Development Advisory Committee of the Health, Food and Welfare Bureau of the Hong Kong Government published a consultative document "Building a Healthy Tomorrow" in which the concept of family medicine and family doctors were placed in a central position in an initiative to revamp the primary healthcare services in Hong Kong. The Hong Kong College of Family Physicians wanted to obtain an up-to-date picture of the public's perception of primary healthcare and their expectations of related services. Accordingly, in early 2006 the College commissioned the Social Sciences Research Centre (SSRC) of the University of Hong Kong to conduct a telephone survey to study the community's expectations of primary healthcare services. Method Following a review of literature1,2 and discussions among members of the Research Committee of the Hong Kong College of Family Physicians, a questionnaire was then thought out. This questionnaire was designed to cover the following areas: Type of primary healthcare service that the public wants, including treatment, appointment system, clinic service hours, doctor's gender, age and attitude; The telephone interview using the CATI system (Computer Assisted Telephone Interview) was conducted by the Social Sciences Research Centre, The University of Hong Kong. Telephone numbers were generated from the 2003 English residential telephone directory by dropping the last digit, removing duplicates, adding all 10 possible final digits, randomizing order, and selecting as needed. This method provides an equal probability sample that covers unlisted and new numbers but excludes large businesses that use blocks of at least 10 numbers. All interviewers were trained in a standardized approach prior to the commencement of the survey. All interviews were conducted by interviewers fluent in Cantonese, Putonghua and English. The SSRC performed quality checks for each stage of the survey to ensure satisfactory standards of performance. At least 5% of the questionnaires completed by each interviewer were checked by the SSRC project manager independently. Eligible respondents were residents in Hong Kong and aged 21 years or above and all were Cantonese or Putonghua speakers. In this survey, domestic helpers were excluded. Where more than one eligible person resided in a household and more than one was present at the time of the telephone contact, the 'Next Birthday' rules were applied to each successfully contacted residential unit, i.e., the household member who had his/her birthday most recently was selected. This reduced over-representation of housewives in the sample. Telephone calls were made between 6:30 p.m. to 10:30 pm on weekdays and 2:00 p.m. to 7:00 pm on Saturdays. The statistical software SPSS for Windows version 13.0 was used to perform all statistical analyses. Results A total of 13,426 telephone calls were made. The number of successful interviews was 1,064. Refusal and drop-out cases totalled 595. For cases which were 'not available' (2,995), and 'no answer' (2,859), three calls were attempted before the case was classified as a non-contact. The contact rate was 42.6%2 and the overall response rate was 64.1%. Table 1 details the breakdown of telephone contact status. The main findings are described below. Sources of primary healthcare Nearly 65% of respondents obtained their primary healthcare services from the private sector, with 45% from private doctors, 9% from company appointed doctors and 11% from out-patient clinics of private hospitals. 35.4% obtained their primary healthcare services from government, university or subvented clinics. Factors affecting the choice of primary healthcare services The three main factors which affected the public's choices were budget (43.4%), convenience (38.8%) and word of mouth recommendation (23.0%). Mode of service 58.7% preferred seeing the same doctor for their illnesses while 31.3% would not mind seeing a different doctor if their doctor was not available. Duration of consultation 32.0% preferred a 10 minute consultation while 30.3% preferred a 15 minute consultation. 15.1% thought a 5 minute consultation was sufficient. Hours of service From Monday to Friday, 17.2% preferred 8 hours in the morning and the afternoon, 12.7% 8 hours in the morning and evening, 45.8% 12 hours in the morning, afternoon and evening, and 24.4% a 24-hour service. Family doctor and primary care doctor 94.4% of the studied population had heard of the term 'family doctor' and 66.1% thought that a family doctor was different from a primary care doctor. The primary care doctor 56.2% have a regular primary care family doctor. Among these, 64.8% thought that their doctor was a general practitioner, 14.2% a family medicine doctor, 5.1% a specialist family physician, and 13% a specialist but not necessarily in family medicine. Among the specialists not in family medicine, 27.3% were paediatricians, 16.9% internal medicine physicians, 7.8% gynaecologists, 6.5% cardiologists, 5.2% an otorhinolaryngologist or a dermatologist. Training of a family doctor 24.2% agreed strongly and 48.6% agreed that primary care doctor should receive formal family medicine training. 12.5% strongly agreed and 41.7% agreed that a family doctor with formal training was a specialist in his own right. A doctor for the family 11.4% strongly agreed and 34.9% agreed with the statement that one's entire family should consult the same primary care doctor. Characteristics of a family doctor 37.9% strongly agreed and 49.1% agreed with the statement that a family doctor should provide a detailed explanation of their medical conditions. 37.3% strongly agreed and 51.3% agreed that the family doctor should discuss the content and reasons for his recommended management decisions. 73.1% thought that the family doctor should spend time dealing with their illnesses. 55.4% expected the family doctor to ask about physical, psychological and social problems. 53.2% thought that the family doctor could deal with all health problems. 81.5% thought they could ask the family doctor for advice on lifestyle, 21.5% also to talk about their marriage problems, 27.2% to talk about their family problems and 25.3% about their work and inter-personal problems. Taking care of chronic illnesses 7.1% strongly agreed, 30.5% agreed and 30.3% were ambivalent about private doctors taking care of chronic illnesses. The family medical practice 27% strongly agreed and 54.3% agreed that primary care doctors should work along side specialty specialists within the same practice in order to facilitate easy referrals. 19.7% strongly agreed and 50.4% agreed that several primary care doctors should work together in the same practice for the patients' convenience. Preventive care 22.4% strongly agreed and 53.1% agreed that primary care doctors should provide preventive care and cancer screening. Moreover, 8.7% strongly agreed and 55.3% agreed that they would pay for these services. Patient records 23.9% strongly agreed and 55.4% agreed that their primary care doctors should have access to their medical records in government hospitals. Discussions The public has become more informed of its choices in primary healthcare services and, as a result, its expectations have grown. The public's demands have become more sophisticated and the concept of family medicine seems to be consistent with some of these expectations. The private sector still provides the majority of primary healthcare. Hence, in any initiative to revamp primary healthcare services, the needs of the private sector, such as resources and training, cannot be ignored. Most citizens preferred seeing the same doctor all the time. Continuity of care is thus perceived to be a valued element in the doctor-patient relationship. This is an important underlying concept in family medicine practice. Nearly half of respondents also thought that the whole family should see the same primary care doctor. This is consistent with the concept of family medicine in which the same doctor should care for the whole family. Understanding the dynamics among different members of the family, the family doctor is positioned to provide holistic individual and family care. The community expects quality care from their primary care doctors and recognizes that formal training in family medicine is desirable. Furthermore, the public recognizes the specialist status of a family physician. A logical implication is that there should be more resources for family medicine training in order to meet the growing community expectations. Two-thirds of respondents preferred a consultation of at least 10 minutes which is consistent with the results from international studies.3-5 Duration longer than 5-10 minutes was also expected by most subjects 10 years ago.1 Longer consultations do allow patients time to discuss problems and concerns and enable their doctors to provide comprehensive and holistic care. However, the service implications in providing longer consultation visits, especially in the government sector, are that we need to enable doctors to have the desired skills in order to provide improved quality care, i.e., more trained primary care doctors. These considerations have direct bearings on manpower planning, resource allocations and appropriate training facilities and personnel. The public regards group practice as a means for improving continuity of care and polyclinics for more comprehensive services. The benefits of group practice and polyclinics at the professional, service and commercial levels have to be assessed against the freedom, independence and autonomy of solo practices. However, to meet public expectations, the government may need to consider what incentives would encourage doctors to work within the same premises. The public regarded service availability as important elements in Hong Kong's healthcare service; less than 25% wanted a 24-hour service. The viability of providing 24-hour primary care clinics has been previously shown to be questionable. If the government wishes to reduce non-urgent visits to Accident and Emergency Departments during periods of the day when private clinics are normally closed, other strategies will need to be considered. Public opinion was divided, in who should take care of those patients with chronic illness. One-third of respondents were satisfied with private doctors following up chronic illnesses. Thus any move to shift responsibility for chronic care from the government sector to the private sector would be acceptable to at least one third of the population. However, associated factors which will influence if the public would widely seek chronic care in the private sector are that sector's availability of facilities, expertise and cost of service. There is significant public support for an effective public-private interface. There is much to be gained from developing a system in which private doctors have access to the Hospital Authority computer records. There is a significant awareness in the community for preventive care and cancer screening. Members of the public were prepared to pay for these services. Accordingly the government would do well to consider promoting preventive care and cancer screening in the private sector so as to lighten its workload and decrease its expenditure. Conclusion The private sector provides the majority of primary healthcare. The community expects a consultation with a primary care doctor of reasonable length and values continuity of care by seeing the same doctor. Members of the public would also like their family members to also see the same doctor. Although most presently see a primary care doctor, they would prefer their doctor to have some formal training in family medicine. Furthermore, they consider a formally trained family physician as a specialist in his own right, and consistent with this, have sophisticated expectations for those who are trained as family doctor specialists. The public would prefer to attend group practices in order to have continuity of care and polyclinics for more comprehensive services. Although they placed service availability as an important element in primary healthcare, less than one quarter needed a 24-hour service. One third of the community would prefer to have their chronic illness followed up in the private sector, and the vast majority would like their doctor to have access to government hospital records. There is a high awareness for preventive care and cancer screening and the community is prepared to pay for the services. The conclusion from this survey is that more resources can be channelled into family medicine training (with the goal that more primary care doctors are equipped with the necessary skills to provide quality primary care), and a better public-private interface mechanism can be developed, and that this reallocation of resources would be welcomed by the community. The survey gives hope that objectives set out in the consultative document "Building a Healthy Tomorrow" are achievable. Key messages
Research Committee, The Hong Kong College of Family Physicians Correspondence to: Dr Ruby S Y Lee, Chairman, Research Committee, HKCFP, 7th Floor, HKAM Jockey Club Building, 99 Wong Chuk Hang Road, Hong Kong. References
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