SCMP Debate

PUBLISHED : Monday, 16 April, 2012, 12:00am
UPDATED : Monday, 16 April, 2012, 12:00am


A major challenge chief executive-elect Leung Chun-ying faces on taking office is improving Hong Kong's hospital system. The medical sector is intended to be one of the city's pillar industries. But hospitals face a chronic shortage of doctors and nurses. Patients must endure dangerously long delays in receiving medical attention, while allocating resources between public and private hospitals has been a perennial problem. In this SCMP debate, we look at the city's hospitals and also call on experts from Singapore's and Taiwan's medical communities to see how they have addressed these pressing issues

SingHealth Group

Professor Ivy Ng, chief executive officer

How does the government address the imbalance between the public and private hospital sectors? How does the private market contribute to easing the pressure on the public sector?

Private and public health care complement each other. With a mix of 80 per cent public and 20 per cent private in Singapore's health care system, our public sector leads the way in terms of how health care is delivered, because almost all doctors and nurses in the private sector were trained within the public health care system. Training of other health care staff and research are largely done in the public sector.

While the public sector ensures delivery of excellent standards of health care service to Singaporeans in an accessible and affordable way, the private sector caters to a lower volume of patients and has more capacity for overseas patients.

Recently, the private sector has also been tasked to help with some subsidised patient load, since they have spare capacity. This is a win-win partnership for both sectors.

The shortage of qualified medical staff is a serious problem in Hong Kong. Do you face a similar problem in your country? And what have you done to address this issue?

Like many countries, Singapore faces the perennial problem of limited resources and competing demands. As the largest public health care group in Singapore, SingHealth, like many organisations, faces a talent war in attracting high-calibre individuals.

As we build greater capabilities and services, equally critical is the need to attract the right talent and nurture a strong supply of health care professionals who are ready and passionate to serve the public. In January 2011, we launched the SingHealth Medicine Scholarship to offer grants to first-year medical students. Our senior leadership team also goes on overseas recruitment trips to attract Singaporeans abroad and others to SingHealth.

Through such initiatives, we hope to encourage bright young medical talent to consider a medical career in the public health care sector and groom them to be future medical leaders.

At the same time, we have to ensure that recognition and rewards are commensurate with the skills and experience we hire. Last month, the Ministry of Health announced the introduction of a new and more competitive pay framework for doctors, nurses and allied health professionals. This is a boost to the public health care sector, because while pay is not everything, it is an important factor in attracting and retaining talent.

The new framework, for instance, will better recognise public sector doctors for the complexity of their clinical work. Many of our doctors take on roles in education, administration, leadership and research on top of their clinical duties. The new framework will no doubt strengthen recognition of such complexity.

Professional growth is another key area of focus. In providing our talent pool with a stimulating environment, we constantly invest in facilities and opportunities that enable our staff to learn and grow. Aside from training programmes and overseas attachments, we offer a structured mentoring programme in which our senior health care professionals pass on their knowledge and share their expertise and experience with the younger generation.

Raffles Medical Group

Dr Prem Kumar Nair, chief corporate officer

How does the government address the imbalance between the public and private hospital sectors? How does the private market contribute to easing the pressure on the public sector?

Singapore has a large public health care sector that has grown significantly to meet the needs of the expanding and ageing population. More public hospitals are being developed. As the utilisation of public health care services is high, leading to overcrowding and increased waiting times, the Ministry of Health has developed several public-private partnership schemes.

One of the schemes taps the private sector's bed capacity. Public hospitals have been renting beds at private hospitals since 2009, and the ministry is currently exploring the possibility of private hospitals taking on some subsidised patient load.

Another successful scheme is the Community Health Assist Scheme, funded by the ministry, where private general practitioners and dental surgeons provide subsidised treatment to needy patients.

The shortage of qualified medical staff is a serious problem in Hong Kong. Do you face a similar problem in your country? And what have you done to address this issue?

Shortages of health care staff, notably doctors, nurses and allied health personnel, are a global problem. Singapore does not produce enough of these professionals to staff our health care facilities.

While we have increased the number of medical schools and polytechnics to train nurses and allied health workers, we bring in significant numbers of foreign staff to man our clinics and hospitals.

To facilitate this, the Singapore Medical Council has accredited close to 160 foreign medical schools whose graduates can be considered for registration locally. Similar accreditation has been extended to other foreign health care staff.

Public and private hospitals are also exploring ways to improve working conditions, and many of these initiatives involve the use of technology - both information technology and process improvement technology.

Hospital Authority

Dr Leung Pak-yin, chief executive

How can the government address the imbalance between the public and private hospital sectors? How can the private market contribute to easing the pressure on the public sector?

The Hospital Authority (HA) values collaboration with the private sector in the provision of health care services for its patients. In recent years, there have been increasing opportunities for public-private partnership (PPP). This mirrors a growing trend in many other advanced economies. PPPs enable effective utilisation of resources by bringing together public and private service providers and facilitates continuity of care and knowledge exchange through enhanced communication and experience sharing.

The combined efforts of the public and private sectors will provide more choices to patients and lead to an overall improvement in service quality.

The HA has introduced several clinical PPP programmes to enhance health care service delivery and patient choice. The Cataract Surgeries Programme aims at shortening the waiting time for cataract surgeries in public hospitals. It has successfully encouraged and facilitated patients in the public sector to receive surgery in the private sector.

A pilot run of the PPP model is being conducted in Tin Shui Wai as the Tin Shui Wai Primary Care Partnership Project for the delivery of primary care and promoting the family doctor concept in the community.

The Haemodialysis Public-Private Partnership Programme is being rolled out with the participation of community haemodialysis service providers. And another project looks to procure some radiology services from the private sector for public patients.

As a major participant in the overall health care reform agenda in Hong Kong, we will continue to support the policy direction of the government and explore more opportunities for PPP.

What measures should be taken to address the shortage of medical staff?

The HA fully recognises the critical shortage of doctors and has strived for more resources and made continuous efforts in attracting and retaining doctors. New initiatives introduced in recent years include introduction of a new career structure, enhancement of promotion prospects, improvement of working conditions, enhancement of training opportunities, enhanced recognition of excessive overnight on-site call duties and vigorous efforts in employing more fully registered doctors as well as part-time doctors.

Despite various measures implemented to address manpower and workload issues, the concern about inadequate doctor manpower can only be eased by increasing the number of local medical graduates. In this light and having considered the public health care needs and patients' interests, the HA decided to recruit non-local doctors under limited registration as an interim measure to alleviate the heavy workload and maintain committed services, particularly in departments with critical manpower situations.

In the long run, the government will increase the number of medical school places to 420, and it is expected that these medical students will graduate and help relieve the manpower constraints in 2018.

The places for nursing and allied health students have also been increased, and the HA has reopened nursing schools to strengthen the supply of healthcare manpower.

What can management do to help frontline staff improve their skills and avoid medical blunders?

Modern health care is a complex undertaking. Advances in medical technology have made available new, effective treatments, but that also brings along new potential risks to patients. While risk can never be reduced to zero, it can hopefully be controlled at an acceptable level.

Towards this end, the HA strives to reduce patient risk and system error through measures to ensure workforce competency at both individual and system level and to develop system measures to reduce patient risk.

Examples include employing automation to ensure transfusion compatibility and using 2-D bar coding technology to ensure correct patient and specimen identification.

The HA attaches great importance to the quality of its services and patient safety. An electronic system was introduced in 2004 to facilitate voluntary reporting of medical incidents. In 2007, the HA implemented the 'sentinel event policy', which requires mandatory reporting of nine categories of incidents. In 2010, it was expanded to incorporate two more categories of 'serious untoward events'.

Under the policy, public hospitals are required to handle such events in accordance with established procedures. Each sentinel event and serious untoward event will be investigated by an expert panel aiming to identify the root cause and come up with improvement measures, which will be implemented to avoid recurrence of similar incidents.

Through this arrangement, the HA aims to minimise harm to patients and provide timely support to family and staff involved.

Formal reports are published annually (, and learning points are shared among staff every three months through newsletters.

In addition, the HA has implemented measures like morbidity and mortality review meetings, clinical audits and patient safety rounds and piloted a hospital accreditation scheme to further enhance patient safety.

Hong Kong Sanatorium & Hospital

Dr Walton Li, medical superintendent

How can the government address the imbalance between the public and private hospital sectors? How can the private market contribute to easing the pressure on the public sector?

In Hong Kong, private hospitals serve to complement the public hospital system. The city is unique in that all 12 private hospitals operate on either a charitable or not-for-profit basis, with any surplus revenue going straight back into infrastructure improvement.

When more patients opt for private medical services, more capacity and resources can be made available in public hospitals to serve those who rely only on the public health care system.

Apart from pricing, private and public hospitals can complement each other in several ways. For example, the two university hospitals that fall under the Hospital Authority are leaders in medical research, while an advanced private medical centre has the resources and flexibility to introduce technology, equipment and treatment procedures in a timely, efficient and effective manner. This is an advantage that public hospitals are unable to provide.

Hong Kong Sanatorium & Hospital (HKSH) has a great working relationship with the university hospitals, and we have been helping to train student doctors for the University of Hong Kong's medical school over the years. We have also been sharing our resources in other ways, such as advanced imaging for public hospital patients at a discounted price. The degree of collaboration has been increasing over the years.

The reality in Hong Kong is that we do not have sufficient hospital beds in both the public and private sectors. At HKSH, some patients have had to be turned away because of full hospital occupancy more than 80 per cent of the time. More private hospital beds are needed to help ease the demand on the public sector.

HKSH and some other private hospitals have expansion plans in the pipeline. The government has also committed itself to providing land for building private hospitals. However, the process of approval is long and, at times, not short of challenges. In this respect, the government can certainly help by facilitating the private sector to assume a greater role in meeting the demands of patients.

As for pricing, given that the public health service is virtually free, the private hospitals need to be able to provide a significant service differential to overcome the great price differential.

For this reason, we must continuously upgrade and improve our facilities, acquire state-of-the-art medical technology and equipment and train and build teams of nursing and supportive staff to work in partnership with the doctors while catering to patients' care and needs.

Only 10 to 15 per cent of HKSH patients are in our private 'first-class' category of accommodation, while 70 to 80 per cent of our patients are being adequately covered by private medical insurance policies. No private hospital can operate and survive by catering only to the rich and privileged.

Thus private medical insurance plays an important and effective role in medical health financing. By building a stronger private sector infrastructure, we can attract more patients to opt for private medical services, and by building more private beds, the private hospitals can certainly help to ease overcrowding in the public sector.

Having more capacity to develop medical tourism means more than just developing one of the key economic pillars and accommodating mainland maternity cases. Excluding mainland maternity cases, over 10 per cent of HKSH patients come from abroad. Many such patients have complex medical and surgical conditions, including cancer. These patients will help to develop our expertise in various specialties and strengthen the quality of health care.

What measures should be taken to address the shortage of medical staff?

Enhancing quality training is the key. In 2004, experienced nurses in the public sector who excelled during the Sars outbreak were, surprisingly, encouraged to retire early. At the same time, there was a reduction in the intake of medical students and the closure of hospital-based nursing schools. These were contrary to the public needs.

Anticipating the need for more nurses, we reactivated our nursing school in 2004, followed by collaboration with the Open University in 2005 and with Polytechnic University in 2008 to train more qualified medical workers. From 2004 to date, we have trained more than 500 nurses. HKSH supported these programmes through donations and scholarships. Currently, we are training about 100 nurses every year.

There is a definite shortage of doctors in the public sector. The distribution between the two sectors is disproportionate in regard to their patient load. The top priority is to support the training of the next generation of medical specialists. At HKSH, we have been trying to help the cause by providing more training.

What can management do to help frontline staff improve their skills and reduce medical blunders?

A good governance framework, effective and quality management and continuous professional training, together with visionary leadership, are the keys to reducing medical blunders.

Hospital accreditation schemes play a vital role in ensuring good clinical and corporate governance with regard to all aspects of patient safety and also in ensuring effective and efficient operation systems are in place that comply with international standards.

With the clinical governance system in place, it is just as important that the staff embrace the culture of quality assurance and system improvement.

For continuous professional training, a system with clinical instructors and mentors has been deployed to supervise and guide new graduates and recruits on work routines until they are proficient and confident enough to take up their posts as independent and effective team members.

A young graduate out of school may find it extremely stressful to be placed in a professionally demanding position. Clinical psychology is an important ingredient in the process. Crisis intervention training is also part of the programme.

In order for us to encourage our staff to develop a caring attitude towards work to reduce medical blunders, we have to show them that we care for their well-being and are readily available to give them the necessary support.

To enhance the team spirit and morale at the front line, active support and presence from the top management is crucial.

National Taiwan University Hospital

Peng Tao-hua, public affairs office specialist

How does the government address the imbalance between the public and private hospital sectors? How does the private market contribute to easing the pressure on the public sector?

Taiwan's system is quite different from Hong Kong's, making comparison difficult, but some of the measures and policies adopted by our government might serve as a reference for Hong Kong.

The National Taiwan University Hospital (NTUH) is a top national medical centre. Unlike the situation in Hong Kong, the number of doctors and medical staff is relatively large compared with those in other public or private hospitals. Also, because of its relatively better medical resources, many patients are more willing to be treated at NTUH, even if they have to wait several days for medical attention.

To resolve the imbalance between public and private hospitals, Taiwan's Department of Health introduced mandatory National Health Insurance. Under this scheme, through premiums and government subsidies, the government covers a large portion of medical charges incurred by patients for treatment at either public or private hospitals.

This helps reduce the problem of doctors moving from either public to private hospitals or vice versa, as public and private hospitals can all afford to pay doctors and medical staff through the scheme.

The shortage of qualified medical staff is a serious problem in Hong Kong. Do you face a similar problem in your country? And what have you done to address this issue?

The National Health Insurance scheme sets a limit on the time physicians and health care staff can devote to giving medical attention to a patient, to avoid overloading them.

From time to time, NTUH will also adjust itself to meet the needs of patients and improve its service.

NTUH does not have to compete for medical staff, because it is a hospital attached to a university.

Each year, fresh blood is provided by the newly graduated students of the university's medical college. Many students also serve as interns in NTUH, to help ease the workload of the regular medical staff.

Many professors at the university are well-known and international-class medical experts or physicians who can either offer advice or join in providing treatment in serious cases.

Heng Chun Christian Hospital

Cheng Li-chih, superintendent

How does the government address the imbalance between the public and private hospital sectors? How does the private market contribute to easing the pressure on the public sector?

In Taiwan, hospitals are classified as medical centres, regional hospitals and local-level hospitals. There is not much difference between public and private hospitals given that Taiwan has a National Health Insurance system.

Under this system, every year the government budgets for each hospital according to the number of patients that will attend as well as the services and medicines it will dispense.

As a result, the medical system in Taiwan is like a public medical care system, with private hospitals also receiving financing or subsidies from the government. This enables the government to have a certain level of control over all hospitals in Taiwan.

The shortage of qualified medical staff is a serious problem in Hong Kong. Do you face a similar problem in your country? And what have you done to address this issue?

An imbalance does exist between hospitals in remote areas and those in urban areas. Not many doctors or medical staff are eager to work at hospitals in remote areas.

There are about 39,000 doctors practising Western medicine in Taiwan, but in a remote area like Hengchun, there are only 75 doctors serving more than 60,000 people, meaning that each doctor has to take care of more than 800 people.

In an urban area like Taipei, which has a population of 2.63 million served by 6,200 doctors, one doctor takes care of about 420 people.

Fortunately, under the National Health Insurance system, medical centres are required to support regional and local-level hospitals, and regional hospitals local-level hospitals. If hospitals in remote areas need support, they can ask for personnel and facilities from medical centres or regional hospitals in an urban area.

To prevent urban hospitals with bigger resources and staff from refusing to provide support, the system has a review mechanism that examines the service quality of each hospital every three years. Hospitals failing to meet the requirement will be downgraded. If a medical centre is found to be not supporting a remote or lower-level hospital, it will be downgraded. This means the medical funds given to this hospital by the government through the health insurance system will be reduced.

Hong Kong could require private hospitals to support public hospitals when needed. After all, the government provides a stable and well-to-do environment for doctors to practise medicine in; they should give back to society by backing up public hospitals.

Taiwan also has a patient referral system that allows smaller hospitals to transfer patients to bigger hospitals, which face serious punishment and heavy fines if they refuse to accept them.

In addition to the funds allocated through the health insurance system, Taiwan also offers certain subsidies to hospitals in remote areas to help ease problems with resources and staff recruitment.


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