Hong Kong’s ailing health care system needs an injection of people-centred policymaking

The report, “Fit for Purpose: A Health System for the 21st Century”, prepared by former health secretary Professor Yeoh Eng-kiong for Our Hong Kong Foundation is timely and relevant. It has shown that the present hospital-based medical system is unsustainable as we face a rapidly ageing society.

Although our life expectancy is increasing, our health is not getting better. At present, the hospitalisation rate of people aged 65 or above is four times higher than those below 65, with older adults taking up more than 50 per cent of all patient days. The public hospital system’s resources have come under tremendous pressure, with the bed occupancy rate frequently exceeding 100 per cent capacity.

Government expenditure on our health care system has been rising every year, for years, even exceeding gross domestic product growth, but it still falls behind the rate of increase in hospitalisation days. To maintain a quality and sustainable health care system, we need to think strategically and act decisively.

Hong Kong needs a two-pronged approach: increasing the supply of medical and health services while decreasing demand without compromising on quality.

With regard to the supply side, we are not only short of doctors but have an imbalance between the private and public hospital systems: public hospitals employ 40 per cent of the doctors, while caring for 90 per cent of the patients.

While the private medical market is flourishing, it is too expensive for most people when it comes to hospitalisation. Private health insurance coverage provides limited support in directing the flow of patients to private hospitals. Some insurance policies actually encourage patients to seek treatment in the public system.

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Despite the manpower shortage, it is extremely difficult for doctors from overseas to qualify to practise here, with the licencing exam having an overall pass rate of only 20 per cent. While legitimate concerns have been raised about ensuring the quality of medical practitioners in Hong Kong, many of the objections have protectionist undertones. Although the city’s medical schools have begun boosting their student intake, it takes over nine years to train a specialist.

In contrast, Singapore has rapidly increased the institutions from which it accepts overseas-trained doctors, to over 150. The number of doctors in Singapore has increased 55 per cent, with a rate of 2.3 per 1,000 people, whereas Hong Kong still only has 1.9 doctors per 1,000.

In fact, the Singapore government has been reluctant to increase the quota for medical students as it wants to ensure that sufficient talent can be spared for other disciplines. A strong government and a more inclusive medical body are needed to implement these policies.

Meanwhile, Hong Kong’s hospital system has been falling behind in using technology to improve its efficiency. The number of people visiting the Hospital Authority’s accident and emergency department fell by 4 per cent after the increase in charges from HK$100 to HK$180, which was intended to curb the number of non-urgent cases showing up at A&E departments. In an ageing society, with more patients with chronic illnesses, the increase in urgent cases may be unavoidable. Instead, if there were 24-hour triage hotlines to help people make informed choices, the number of admissions could be substantially reduced.

Why doesn’t Hong Kong have more after-hours clinics, which could operate at a lower cost than A&E departments? Raising fees will not make a substantial difference if there are no supporting measures in place.

Scheme for public patients to use private care ‘should be expanded’

Also, Hong Kong has not really embraced the public health approach to keeping our population fit by promoting a healthier lifestyle. Long working hours and less physical exercise have been shown to be important in diminishing our wellness. Deprived living conditions also pose adverse risks to physical and mental health.

We must move away from a conventional health care system that focuses on acute hospital-centric care to primary care-led integrated people-centred care. This requires a change in the mindset of leaders and health care providers to make possible the transition from a disease-focused and doctor-centred system to people-centred care that encourages individuals to take ownership of their own health.

In addition, even as we aim towards helping more people remain free from physical illness, we also need to work on maintaining good mental health, as the World Health Organisation has been championing.

For example, sleep deprivation is a serious health issue that has been ignored in the community. Prescribing sleeping pills does not do as much to promote wellness as encouraging a healthy work and living environment. This is more than a health sector problem.

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With improved work safety, many of the 35,631 cases of occupation-related accidents in 2017 could have been avoided, while enhanced road safety would also reduce injuries. If we could improve the living conditions of the 300,000 or so people who are queuing for public housing, as well as air quality, the number who suffer from flu and respiratory diseases would also decline. If we provide more public space and recreational and leisure activities, our overall physical and mental health would improve. Prevention is, after all, better than cure.

In sum, while there is no quick fix for our health care system, if stakeholders look at the big picture and put patients at the centre of policymaking, we have a chance to build a people-centred and integrated health system that is efficient and sustainable.

Paul Yip is chair professor (population health) in the Department of Social Work and Social Administration at the University of Hong Kong