Reform on the road

Libby HY Lee 李夏茵

HK Pract 2023;45:81-83

Lately, there are some very interesting and most diverse discussions in our city.

We are very excited about the current development of advanced technology in curative medicine like CART therapy, production of other advanced therapy products and genomic medicine. However, at the same time we invite our public to focus more on preventive medicine, like changing our lifestyle, doing more exercise, eating less processed food, less salt, less sugar and less fat.

At one end, we are tireless to strengthen our clinical medicine to improve survival and increase longevity. At the other end, we are overwhelmed by the ageing population.

We are enthusiastic in developing artificial intelligence and machine learning that involve the development of algorithms and models that enable computers to learn from data and make predictions or decisions based on that learning. However, we said it is imperative to protect data privacy.

In our professional development, we are moving towards specialisation, if not over-specialisation, while we know we need more general practice to cover the general medical needs of our people.

In most countries, the healthcare fiscal burden is spiralling and escalating out of control. The global and local economy is shrinking. Some of our local advocates strive for a free and easy access to good quality healthcare services. The very same group of people opposes any fee adjustment in any public services, or taxation, to support the escalating healthcare burden.

We are in the era that is full of contrasts. Carl Jung said the greater the contrast, the greater the potential. Great energy only comes from a correspondingly great tension of opposites. But are these really polarised views? Could we have them all?

It is the best time to zoom out. When we look deeper, these views are not that contrasting at all. In fact, they complement each other, only if we are able to re-design our healthcare system to harmonise the perceived competition. At the core of these views, it lies the same passion. We want our people to stay healthy. This should be our first and only first priority, well before developing healthcare services provision into an income generator for the city.

Healthcare reform

In order to achieve the above, we will need a radical change, in mindset, in culture, in the system, in policy, in financing model, and in data protection. We are not alone when we are talking about healthcare reform. In this post-COVID era, many countries are woken up by the cruel fact that the resilience of health system was not there as they wish.

Singapore is implementing something very similar to ours: Healthier Singapore. It emphases on primary healthcare development, strategies for chronic diseases and elders, and reduction of drug costs for general practitioners through bulk purchasing.

Australia is reforming her healthcare financing from fee for service to almost capitation. They are looking at providing financial incentives for reducing hospital admissions and preventive medicine.

United Kingdom uses reform to address their needs from COVID recovery. They want to manage their ageing population and chronic diseases through disease prevention, personalisation by adopting technology as well as enhancing performance of their National Health Services.

Our local situation - Aim right

All of us are facing similar challenges, changing demographics and diseases, rising patient expectations, addressing the injustices of widespread disparities and dealing with an unsustainable financial trajectory. Doing nothing at this juncture risks locking us into a decade of decline. It is not we would simply stand still: we’d actually go backwards.

Most of the countries are reforming for their survival, but for us, we reform for our survival and advancement. It is simply because we have very strong foundation here: our establishment of post-graduation training and professional standard, as well as strong Government commitment in providing public healthcare services. We want to improve the health status of our people, decrease the prevalence of preventable diseases so that we can free up our resources e.g. human capital, financial resources, facility provision, to advance our clinical practice, be it the technology or service models. Here it is the original intention of our reform. Our strategy is to aim right, start small, and last long.

We age and age rapidly. 20% of our population is more than 65 years-old in 2023, and it rises to around 35% in ten years’ time. It significantly affects the elderly dependency ratio. At the current moment, 3.2 person aged 15-64 is supporting an elder aged 65 or above. Take the example of our fellows-to-be. Let’s say you are 30 years old and plan to have your own family right after your fellowship. Let’s look at the situation when you are 65 years old. The elderly dependency ratio is 1.6. So in order to support you and your spouse, you probably need to have 3.2 babies. Our next generation is the one who bears most of the burden.

Chronic disease is the top killer worldwide, accounting for 71% of deaths annually. In Hong Kong, the situation is worrying. We had 2 million people with chronic diseases at the moment. One quarter of our people at the age 45-54, half of the 55-64 age group and three quarters of those more than 65 have chronic diseases. The most common ones are diabetes, hypercholesterolaemia and hypertension.

Study has shown that about half of the diabetes or hypertension are remained undiagnosed. The data from the Hospital Authority showed that every increase in 5 years of age since age 45, there will be a 10% increase in the number of chronic disease patients. With the current trend, if we do nothing about it, there will be 3 millions of people having chronic disease by 2039 which is much faster than we age. The most alarming part is one-third of our diabetic or hypertensive patients will present very late with complications. Not to say the healthcare cost for cases with complications is two times higher, the quality of life of these patients will be significantly jeopardised.

This is most disappointing and definitely requires more attention and reflection. Only 39% of our population has a regular family doctor. Only 40% eligible group enrolled themselves to colorectal cancer screening and 50% to cervical cancer screening. 10% of us still smoke despite the common knowledge of smoking is hazardous to health. 9% of us are regular drinker and 3% are binge drinker. One quarter of us do not have enough exercise. Health behaviour is the most cost effective yet most difficult way to bring health to our people.

Hong Kong, is one of the kind in the world that runs a highly subsidised public healthcare services. We are also the rare-do among the developed countries using the very traditional block vote system to fund our public hospital services. It is not fee for service, which boosts up output. It is not performance-based to drive for cost-efficiency. It is not by capitation to drive for preventive care or integration of primary healthcare and hospital system. We are spending around 7.3% of our Gross Domestic Product (GDP) in healthcare. The total health expenditure amounted to $200 billion in 2020/21, with annual per capita spending at $26,720. We are using 29.3% of our total tax revenue for the current public health expenditure. Of course the majority goes to the Hospital Authority. From 1989/90 to 2019/20, total health expenditure rose at an average annual rate of 5.6% in real terms, faster than the corresponding increase of 3.4% in GDP during the same period. Government projects we are going to spend $315 billion on total health expenditure that is around 9.2% GDP in 2033. Honestly, it is not affordable nor sustainable.

Health inequity is also an issue. Inverse care law is present. High income per capita is found to be related to people with lower number of chronic diseases. Total primary healthcare utilisation is higher for affluent elderly, though they have lower health needs.

Our local situation – Start small

In gist, there is no time to waste to reform and improve the health status of our people, now and beyond. I do not think I need to convince you, out of all people in the healthcare community, the importance of primary healthcare in this reform. Yet, I would like to convince you the steps we are going to take to achieve our bigger picture and brighter future.

There is a saying, public policy follows straightly the Newton’s third law. For every action there is an equal and opposite reaction. Whenever someone comes up with a new idea in public policy, someone else opposes it and a vigorous debate ensues, on intellectual and ideological grounds. When the fog lifts, occasionally we can vaguely discern a winner and the policy starts to shift. Or sometimes, things don’t change much at all because two sides have fought things to a standstill. Our policy on healthcare reform has the same fate in the past 30 years.

In 1990, we have the first Government report on primary healthcare, namely “Health for All, the Way Forward”, which examined the primary care system in Hong Kong at that time and recommended strategies for enhancing and reforming primary care. However, the power of inertia is strong. Things remained standstill for ten years before the next policy paper came out, “Lifelong Investment in Health” in 2000. Since then we have policy paper every 3 to 5 years. Things are slowly enhanced but not to the pace that we would like to have.

We have learnt our lesson throughout the years. Much of the public is conditioned to thinking that reform consists of large, singular actions – generally with a high profile and a measure of public controversy. But there is no big bang reform that will get us where we want to go in a short period of time. This is the famous quote from President Xi, “改革永遠在路上 Reform on the Road”. Instead, this time, we break down the reform into pieces and build up momentum to keep the ball rolling.

Last year, the Government has published the Primary Healthcare Blueprint. Although the work was started since the last term of Government, I hope you appreciate the latest version did have quite some changes to the very original idea. For example, on top of just focusing on the community-based system, we added the component of family physicians in the Blueprint, stressing everyone should have their own family doctor. More importantly, we placed more emphasis on infrastructure strengthening like governance, resources, manpower as well as data connectivity. These infrastructure changes are not randomly designed but intentional to pave the path for the forthcoming reforms.

We follow the Newton’s second law. The acceleration of an object is dependent upon two variables – the net force acting upon the object and the mass of the object. This time the force is bigger while the mass we would like to move is much smaller. We focus on system reforms and intentionally leave out the financing reforms, insurance coverage reforms, data reforms, and other policy reforms behind till the infrastructures are mature.

Our local situation - Last long

Apart from laying down the infrastructure as in the Blueprint, a piece of jigsaw is still required to keep the reform on the right track. This is professionalism. Without this important software, reform will not be possible nor last long.

Professionalism is at the core of medical practice and forms the basis of medicine’s contract with society. The society, the patients expect our professionals to be compassionate, altruistic and trustworthy. These attributes are not just moral terms but a translation of values into daily actions.

There are at least 4 key elements supporting professionalism.

• Awareness of and adherence to, standards of care. This is professional competence requiring continuing professional development/medical education.
• Responsiveness to patients’ individual clinical and emotional needs. The ability of our family doctors to develop a trustworthy relationship with their patients are the cornerstone of our primary healthcare development.
• Engagement to working in partnership with patients, colleagues, and administrators. Health issues are getting more complex and patient’s expectation is rising. Adopting a multidisciplinary approach and involving and empowering patients will be the key formula in modern medicine.
• Acting with integrity and participating in the process of professionally-led regulation, including holding each other accountable for our actions. It includes but not limits to protect confidentiality and privacy, accept professional responsibilities and accountabilities.

Conclusion

I have just shared with you about the thoughts we have on healthcare reform. Hope that we, together, have the patience, wisdom and solidarity to fight for the betterment of our people. In fact, there is a second sentence in President Xi’s quote of 改革永遠在路上. It is 改革之路無坦途. We understand that it is not easy, but necessary. Let’s work together!

Thank you.