If opening up the mainland health care market under the Closer Economic Partnership Arrangement (Cepa) is a present from Beijing to Hong Kong medical service providers, it is a gift voucher that has yet to be redeemed. Since the first generation of Cepa, introduced in 2005, allowed Hong Kong doctors and dentists to practise up north, those who have tried to exploit the new opportunity have struggled with red tape, an information blackout and investor disinterest. Some have shelved plans because of a sudden change in policies; some failed to get professional indemnity protection; while others fear what could happen in the event of a medical legal case. That is why there were no big cheers from local practitioners when the latest Cepa deal with Guangdong - allowing Hong Kong doctors and dentists to practise solo in the province without having to sit a mainland licensing examination - was announced in July. Instead, a wait-and-see attitude prevails, until details of how the system will work emerge. The latest economic pact, effective from January, will permit Hong Kong doctors and dentists to set up wholly owned outpatient clinics in Guangdong with no minimum investment requirement. The practitioners are also exempted from sitting the mainland examination and obtaining medical practitioner qualification certificates through accreditation. The previous Cepa arrangement required a minimum joint-venture investment of 10 million yuan (HK$11.3 million). The response was poor. Medical Association president Tse Hung-hing said most Hong Kong doctors had snubbed Cepa because of uncertainties and risks. The key concern was the legal liabilities. While doctors in Hong Kong are covered by the Medical Protection Society (MPS) for professional indemnity, they cannot get the same protection on the mainland. Dr Tse said the MPS provided only selective protection to Hong Kong doctors who practised on the mainland and there was no guarantee they could be insured at all. Some doctors have complained to the Medical Association about the lack of insurance coverage. 'We don't know about the medical legal system on the mainland; there are no statistics available on compensation given out on medical legal cases, so it is difficult for an insurance company to work out a plan in the first place,' Dr Tse said. 'Medical practice is always very high risk. 'Without a clear policy on professional indemnity, Hong Kong doctors will not feel safe practising on the mainland.' Private Hospitals' Association president Alan Lau Kwok-lam said local private hospitals had no plans to set up satellite hospitals on the mainland because of the potential business risk. 'We are unclear what responsibilities doctors and hospitals have to bear if some medical incidents happen,' Dr Lau said. 'We simply don't understand the mainland legal system there. The private hospital business takes a long time to get a return, at least 10 or 15 years.' For the Union Hospital in Sha Tin, one of the city's 12 private hospitals, red tape and a lack of mainland business know-how have been hurdles to its plan to open a hair implant centre in Guangzhou. The hospital's medical director, Anthony Lee Kai-yiu, said the centre was expected to act as a window to Hong Kong for potential mainland medical tourists. After more than a year, the plan is still on the drawing board. Last year, the hospital's parent company, property developer Henderson Group, had a vacant premises in Guangzhou for the centre but the hospital could not find a local partner. At the time, Cepa only allowed a Hong Kong operator to have a joint venture with a mainland partner. The site later became a shopping centre. Earlier this year, the hospital was in talks about the project with a Guangzhou teaching hospital but the plan was shelved, this time because of a reshuffle of the hospital's leadership. Now on its third attempt, the Union Hospital is working with a private health care operator and has appointed a consultant to help it obtain a business licence. The consultant report said, however, that it would take the hospital at least 14 to 15 months to get a business licence for such a joint venture. 'We need to rent a premises first and leave it vacant for more than a year to get the licence - it is part of the undesirable cost of running a business on the mainland,' Dr Lee said. The hospital will also look into proceeding with a wholly owned model instead of a joint venture after the new Guangdong Cepa deal takes effect. Dr Lee complained of an information blackout when it came to turning the Cepa agreement from words into reality. 'There have never been any briefings to Hong Kong service providers on how it can be done. It would be good if there was a designated office on the mainland to help Hong Kong businesses to explore Cepa,' he said. Dr Lee said the biggest obstacle to opening a hospital on the mainland was a lack of expertise. 'People are the key. Health care services are very labour intensive,' he said. 'A hospital must have a good team of doctors, nurses, allied health and laboratories staff. I don't think we can get such a team on the mainland to provide the Hong Kong-style of care. 'Our name will be at stake if we open a new hospital on the mainland. If we cannot provide good-quality care, our reputation in Hong Kong will be damaged as well.' It has been a similar story for private orthopaedist Ko Wing-man and his teammates. He and 13 others were the first batch of local practitioners to practise on the mainland under Cepa. Since September 2005, they have practised part-time at the Clifford Hospital in Panyu , Guangdong. Dr Ko and two other orthopaedists - St Paul's Hospital medical superintendent David Fang Jin-sheng and former Public Doctors Association president Poon Tak-lun - also set up a shell company a few years ago to explore opportunities to run a hospital on the mainland. Dr Ko, also a former director of the Hospital Authority, which runs more than 40 public hospitals, is keen to provide management and clinical services to mainland hospitals. His idea is to get investors to build either a medium-sized hospital with 300 to 500 beds or to turn a mainland hospital into a Hong Kong-mainland joint venture. A dozen Hong Kong doctors have expressed interest. At one stage, Dr Ko's team had a potential investor for a new hospital in Beijing, but the investor changed his mind and switched to a hotel project. 'We understand that very few people are keen on health care services because the risk is too high and the return is slow compared to a property or hotel project,' Dr Ko said. The team's second plan, to buy a Shanghai hospital, was also aborted because of a change in government leadership of that city. Dr Ko said the latest Cepa arrangement with Guangdong was attractive to Hong Kong doctors who wanted to promote family medicine. 'Family medicine is not popular on the mainland where patients all go to hospitals for all kind of treatments, including minor ones,' he said. 'It is a good chance for Hong Kong doctors to open clinics there to provide primary services.' Another Hong Kong private doctor, who requested anonymity, agreed that Cepa could improve the quality of medical care on the mainland by skills transfers in management and clinical practices. 'If you go to mainland shopping malls, hotels, offices or restaurants, they are basically the same as those you see in Hong Kong. But, once you walk into a mainland hospital, you can immediately feel the big difference,' he said. 'Patients there pay a few yuan registration fee and then have to pay for expensive medicine. When we talk about Hong Kong and mainland integration, health care institutions are among the last to go.' Life seems to be easier for Hong Kong dentists who practise on the mainland because dental clinics are relatively easy, and cheaper, to start up. Raymond Lee Kin-man, a local dentist who has been practising in Beijing, said the latest Cepa arrangement was attractive. A specialist in family dentistry who owns a group practice of more than 10 clinics in Hong Kong, he sat his licensing exam in Beijing in 2005 and was able to practise in the capital. 'Some corporate clients have asked us if we also have branches on the mainland to treat their staff working there, so we can see the potential market there for Hong Kong dentists,' he said. He said Cepa was better for group practices than solo practitioners. 'To a well established dentist in Central, for example, business is good and there is not much incentive for him to uproot both his business and family in Hong Kong and move to the north,' he said. 'But, for a group, we can provide management services and skills transfer to local dentists.' He said that in order to make a dental practice 'financially sustainable' on the mainland, it had to perform high-skill services such as teeth implants and cosmetic services like whitening. 'Local mainland patients have been enjoying cheap services for minor procedures from local clinics, they may not be willing to pay much more for a Hong Kong-style service,' he said.