Supplement for the People of Hong Kong
Improving the Health Care System of Hong Kong
Change to improve
Not for the sake of changing
August 1999
The Hong Kong Medical Association
Paper in response to the Harvard Report


Soon after the publication of the report of the study of the Health Care System in Hong Kong commissioned by the Health & Welfare Bureau of the HKSAR Government (Harvard Report) on 12 April 1999, the Hong Kong Medical Association organized a series of Members' Forum in various districts and hospitals. The face to face discussion was found most effective in the collection of views and exchange of views and comments on the Harvard Report. A total of 17 HKMA Members' Forums were held. In addition, the Council of the Hong Kong Medical Association also received views from members as well as the public via the phone, fax, e-mail and person-to-person discussions.

On the following pages are the aggregate views of members of the Association to the Harvard Report and was submitted to the Health & Welfare Bureau on 14 August 1999. It is also published as a supplement for the people of Hong Kong on this subject of improving the health of Hong Kong.

The Hong Kong Medical Association
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The HKMA Supplement for the People of Hong Kong:


1. In relation to the development of the provision of the health care services, the government produced two White Papers in 1964 and 1974 respectively. A consultancy report commissioned by the Secretary for Health and Welfare, the Scott Report, focusing on hospital services was produced in 1983. Implementation of this report subsequently resulted in the formation of the Hospital Authority. In 1990, the Government released a report of the Working Party on Primary health Care but few recommendations in this report have been implemented. In 1993, the government issued a consultation paper, commonly known as the "Rainbow document" [touching mostly on charges and fees]. This, however, finally faded away (as rainbows do) and did not bring about any change. In addition, a White Paper on "Rehabilitation - Equal Opportunities and Full Participation: A Better Tomorrow" was published in 1995. Apart from these few and far policy papers, there was little expression by the government on any overall health care policy in post-World War II Hong Kong.

2. Many in the community, including the medical profession itself, have pointed out the pitfall of this void in overall health care policy and planning. Still, little progress was made for years in this respect.

3. Then there appeared the trend of increasing reliance by the public on public hospital services with consequential strain on the government budget. Upon the handover of the administration of Hong Kong to China in 1997, a consultancy team from Harvard University was commissioned by the government to study the provision of health care services in Hong Kong.

4. After much reporting in the local media of information alleged to be the findings of the team in early 1999, the team formally released its full final report (hereafter referred to as "The Harvard Report") with the long title "Improving Hong Kong's Health Care System: Why and For Whom?" on 12th April 1999. This full final report was publicized and released by the Health and Welfare Bureau of the Hong Kong SAR Government on the same day by three documents: one introductory pamphlet, one Executive Summary (of 21 pages) and one full copy of the Harvard Report consisting of the Executive Summary, the full contents of the Harvard Report and the supplementary information and study reports (of 490 pages).

5. Although the reason, the exact process and the task, for which the team was chosen to do, were obscure in the public eye, it is stated in the Executive Summary of the Harvard Report under paragraph 1.1 that: "This study was to include a comprehensive assessment of the current system and a proposal for alternative options to improve financing and delivery of health care. In particular, the study aimed to answer the following questions:

(Slightly different wordings are being used to state the objectives in Chapter 3 Objectives and Methods of the Study under paragraph 3.1)

It is further stated that the answers to these questions will differ depending on the perspective from which the assessment is made. This study used "a patient-centered approach, basing our findings mainly on the patients' perspective."

The report further proclaims to adopt "an Evidenced-based, consultative approach" as expounded in paragraph 1.2 of the Executive Summary and in paragraph 3.2 of Chapter 3 of the Harvard Report.

Aim: To safeguard the health of the people by helping to better inform
6. It is against this background that the Hong Kong citizens, whom the medical profession belongs to and form part of, received the Harvard Report. The medical profession has long noted the importance and necessity of careful study on health care policy and planning. The Hong Kong Medical Association ("HKMA") having a membership of over 5,000 doctors and representing the majority of the registered medical practitioners in Hong Kong no doubt has great concern for all aspects of the provision of health care services in Hong Kong. Such concern arises not merely from its effect on the medical profession itself but certainly, and indeed more so, from the time-honoured tradition and convention of the medical profession "to safeguard the health of the people" as enshrined in the Association motto of HKMA. For that purpose and with that particular objective in mind, HKMA prepared this Supplement for the sake and for the perusal of the people of Hong Kong. That this Supplement may help to safeguard the health of the people stems from the belief that any policy on health care services is and should be a choice of the society basing on its culture, preference and value judgment. Before any society can properly make such a choice, it should be well informed. By reason of the long void in health care policy, there is understandably a big question mark on how well the Hong Kong people are being informed in this aspect. It is for that matter that HKMA wish to serve a useful role. This Supplement aims to provide more information to the Hong Kong people on issues of health care services in Hong Kong in general and in particular those raised in the Harvard Report. Hopefully, Hong Kong people will then be better informed and equipped to discuss the issues involved, be able to analyze the various proposals put forward for these issues and be able to form a view an informed view thereafter. As such, it must be unambiguously stated that promoting the interest of the medical profession is not the aim of this Supplement, as many would like to label automatically any action of the medical profession itself. Instead, this Supplement aims to serve the best interest of the people of Hong Kong and therefore the society of Hong Kong as a whole. This supplement does not claim or intend to be comprehensive. Instead it attempts to put forward salient points in the subject in simple and understandable terms without complicated jargons.

Objectives of change (reform), if any
7. It would be useful to assess the current system in terms of strength and weaknesses, as the Harvard Report has done, to help one to focus on what needs to be changed. If something is considered to be good currently, priority must be given to retain it and that it should not be removed for no good reason or for no definite advantageous outcome. It must be pointed out that when changes are made, they should be made for improvement. Changes should not be made merely for the sake of changing, or in the vague hope of something good may happen in the end.

Health Care Financing: General Features
8. It would be helpful to consider the various aspects of health care policy and administration in separate and delineated areas, though each may be interrelated and interacted with each other. By itself and in relation to the contents of the Harvard Report, discussion can be separately considered in three areas: (1) health care financing, (2) delivery system and (3) management and assessment of providers. Understandably, there will be much overlap in the consideration between these three areas.

9. Health care financing generally receives much, and in many cases, the most attention in any debate on health care services. The resources for the health care services of the Hong Kong community necessarily come from the people of Hong Kong themselves. The real discussion concerns about who pays what and how to pay.

10. The government provides annually, from public funds collected as general revenue, in its annual budget, a sum designated to health care services. At present, this constitutes about 14 % of the government budget and is one of the most important sources of health care financing currently. This is important not only because of its size (which represents about half of the total health care expenditure territory-wide) but also because of the following facts:

(a) it is the resource fund for the government to pursue its stated policy that "No one shall be deprived of reasonable medical service by reason of lack of means";

(b) it is the resource fund for the government to perform its role and function in public health;

(c) it is the resource fund for a health service which, as it stands now, takes care of about 93% of the total hospital service and about 15% of outpatient service delivered in Hong Kong;

all of which make it not only a very important source of funding but also a funding for services, which affects nearly everyone in Hong Kong.

11. The role and the policy of the government obviously make it vulnerable to change in health care service costs. Such costs, however, are predicted to rise, perhaps to a different degree under different estimate models and assumptions. Demographic changes, medical and technological changes (advancements) leading to different modalities of treatment, may all lead to changes, and often increases, in health care service costs. That being the case, it is not surprising that the government may come to be concerned with the possibility that health care services, particularly the kind and as financed by the government, may eat up a larger absolute amount as well as proportion of the government budget. This is not only undesirable but may also be contrary to the Basic Law which calls for prudent financial management. So it is understandable that the government is keen to be concerned with considerations for any alternative mode (or reform) for financing health care services. This is one background information that whoever considering the current issues should be fully aware of before he or she can come to any proposal for solution.

12. While the government may anticipate future financial difficulty in continuing its current course in funding health care services, personal difficulty in financing one's own health care cost may also be expected if one does not plan well for any of the anticipated increase in health care costs or there is no subsidy or coverage from the government in some needy circumstances. Health care service is one thing that every body may need at some point in time but the cost of which may be difficult to estimate. Some people may not be able to afford sufficient provision for that at all. Any proposal for financing health care services must deal with the government's problem while addressing a general issue of how to provide financially for the health care service needs of the many different individuals amongst the general public. So obviously it is a quest that has two facets.

13. There are five "options" proposed in the Harvard Report. It is observed that option E as proposed is a variation on option D. So it can be said that there are indeed a mere four and a half options proposed. For each of these, we have the following observations and/or comments.

Harvard Option A
14. Option A is one for maintaining the status quo. While that option has been thrown out almost immediately without discussion in the Harvard Report, there is available some learned opinion that it may still be viable financially for the government budget to have the government budgeting 14% of its annual expenditure on health care services. Maintaining the status quo of course has the advantage of (1) simple to implement; (2) all merits and advantages of the current system will be retained. On the other hand, it certainly will have the disadvantages of (1) risking future financial difficulty if assumption of viability fails; (2) no matter how good the current system is and how well it can stand in the future, it understandably will have some imperfection in it. Maintaining the status quo will not help in curing such imperfections.

Harvard Option B
15. Option B of the Harvard Report is one for capping the government budget. This also has been brushed aside directly. Obviously this is one option which deals with the government side of the problem of health care financing. However, there are several features that should be noted in this option. First, what is meant by capping government budget may mean differently to different people? If it is to mean limiting the government spending on health care services to some percentage of the government budget and no more, then it will be part and parcel of any financing option that is to deal with the government side of the financing problem. Secondly, it should be noted that capping the Government budget is to be rejected as an option by itself because it does not deal with the rest of the financing problem other than those of the government, but not because it is not an objective that one looks for. Indeed, it is one very important objective that any action finally taken will aim at. So coupled with other measures to deal with the rest of the financing problem, capping government budget at some point may be part of the solution to the whole financing problem. Some would perhaps go so much as to say that inherently it would have to be part of any solution.

Harvard Option C
16. Option C of the Harvard Report is one for charging users. Again it is being rejected in the report almost directly because it is estimated that if everyone is to pay for oneself, then the cost may be too high for most to bear. It has however, the advantage of focusing the responsibility to pay to those who use and so avoids abuse (what some may term demand side moral hazard). This "unaffordable" difficulty is particularly prominent because the Harvard Report is considering it singularly, i.e.; there is no combination with any other measures. It is considered in the simple context that anyone who uses the service pays for that service in full. It is too simplistic a system to exist and be void of flaws. Any system on such basis alone of course cannot be accepted. However, as a complementary element to other options, it may have the merit of avoiding abuse (as mentioned above). Used appropriately (to be determined politically), it can help in redistributing the government's subsidy from those who can afford to pay (or can afford to pay a portion) to those who cannot afford to pay (or can only afford to pay a portion). This will help optimizing the effect of the limited resources of the government in actually subsidizing those who needs it.

Harvard Option D
17. Option D is one for seeking contribution from the working population to put into the same pool as the government funding goes, so helping to form a bigger pool. It is in effect asking people to contribute for the government to spend for them. Many consider it to be, in effect, a form of tax (though the Harvard Report does not use that term). It is coupled with the "money follows the patient" idea in the Harvard Report to make it attractive and looks like a social insurance system. It has the advantage of providing additional resources without affecting the general tax rate (in name). However, it also has the disadvantage of focusing the drawing of the additional resources only on those who work and their employers. Of course, if corporations or other origin of income are involved, then, it may be truly considered to be a tax increase. However, that will equally make that source of additional resources drawn from a broader and more stable basis.

18. The so called "money follows the patient" idea, though hailed to offer choice to the patient may not turn out to be advantageous to the consumers when the providers compete merely on price terms. Further, having being made acutely conscious of their own contribution, the mentality of using it may lead to abuses in usage (again demand side moral hazard). What, however, discredits this option most is that it does not seem to concur with the local mentality and culture. Additional contribution to a big pool for general use is not an idea that will be well received locally. If additional contribution from the public is to be adopted, various options, including for example medical savings account, should be considered and consulted with the public beforehand.

19. It should further be noted that the pool of fund to which contribution is made and from which the money will follow the patient is one designated mainly for use for in-patient hospital services and some chronic disease outpatient services only. The inclusion of services similar or close to those now delivered by the present public hospital systems is to be noted. Some consider this as an indication of a system of seeking additional fund to service areas presently funded by government from general revenue only. This helps to reinforce the thinking that the proposals of the Harvard Reports deal with the government side only, rather than a comprehensive solution, of the health care services finance problem.

20. One feature in Option D is the establishment of a fund for old age care. There is good reason for making specific provision for old age care. Demographic studies suggest to us that aged people will form an increasing proportion of the Hong Kong population. Obviously there will be genuine health needs by them. Provision of adequate care for our aged population must be planned for. However, it should be pointed out that the suggestion and the estimate for this old age provision in the Harvard Report might not be sufficient both in extent and in degree. It must be pointed out and made clear to the general public that what is said to be provided for by this old age scheme (MEDISAGE in the Harvard Report) is only for old age home kind of care, not for the most needed, often expensive medical treatment expenses.

Harvard Option E
21. As mentioned above, the Option E in the Harvard Report is only a variation of Option D plus the additional proposal for the setting up of 12 to 18 integrated health care systems in place of the current system. The addition is not exactly a proposal for health care financing but one for delivery system only. As such it may be more appropriate to elaborate on it when we discussed delivery systems below. Suffice to say the concern most people expressed is that such a disintegration and reintegration of the current system may produce a new kind of disconnection amongst the different integrated health care systems. Further there will be additional danger of unnecessary and wasteful overlap of service and equipment.

Harvard Report's Discussion of Options
22. The discussion and choice of options in the Harvard Report have not exhausted the possible options, even though there are not too many. What is more alarming is the singular use of one measure as an option to determine its viability and feasibility. That by itself is not an appropriate mode of consideration since integrating different measures may have the advantage of using the merits of one to offset the faults of another. That complementary approach apparently has not been taken or considered.

Current Government Policy: The Inherently Impossible Moving Target
23. Noting the two facets of the health care financing, and to focus on the government side of the problem, one must take note of the current government policy of ensuring no one be deprived of reasonable medical service by reason of lack of means is, in itself, an ambiguous one. It is ambiguous in not being able to define what is reasonable medical service and who is considered to be lacking of means. The answers for these would be variable and different for different people and at different times. The objective of the government is thus a moving one. This moving target problem is particularly relevant and important in a matter in the nature of health care services where it is to be expected that people will always aim higher and higher and for better service. So the target is not only different for different people at different times, it is inherently impossible to fulfill. If the government continues with such an inherently impossible target, it will never solve its health care financing problem because when it has reached certain point, which the government would have considered to be its target, more will be expected of it and more money (finance) will be needed.
A Parameter of Services

24. This moving target problem can only be solved if the government can set itself some fixed parameters to work towards. The government must be able to say and the public must accept that resources are limited and that limited resources can achieve only limited targets. Conversely, that would mean that limited targets must be set for limited resources. This is the practical issue that both the government and the public must accept.

Parameter Defined by Service Areas and Subsidy Level
25. That a parameter of service target must be set for the government is a practical reality that the government must accept. We cannot rest on an uncertain and ambiguous statement to muddle through any more. What is the parameter is obviously a decision for the society itself, and for that, is a political decision. The exact mechanism will have to be worked out politically. What, however, can be noted is that such parameter need not be limited in terms of service item or areas but can also be based on subsidy level. That may produce a picture of more service item with varied degree of government involvement or subsidy.

Combination Approach for Funding
26. As far as the exact mechanism for collection of more funding, it is already commented that the proposed options are singularly simplistic to be practical. Upon the above comments, it is suggested that upon a defined parameter for government subsidy and involvement, a combination of approaches, say capping the government budget, user-pay mechanism and others may be considered as additional sources of funding for health care services rather than relying on any one particular mode only.

Patients Culture
27. No recognition and discussion have been given to the importance of patient culture in the planning and effective implementation of health care policy and system. Patientss culture represents the general understanding, beliefs and behaviour pattern of patients (potential and actual) in utilizing the health care services. Recognizing patients' culture and to take it into account when planning any healthcare service are most important for the effective use and optimal benefit of our healthcare system.

Delivery System
28. Coming to delivery system, it is important to note that, in essence, the Harvard Report has focused on only one proposal. As far as the pool of resources held by the government (after contribution from the general revenue as part of the government budget and collection from compulsory contributions from workers) is concerned, all health care service providers will have to bid for its share by attracting people to subscribe for its service. The share of funding each health care provider gets will depend on the size of its subscribing population. This is said to be providing for equal competition opportunity so that private health services providers will not be disadvantaged by the heavy subsidy that public hospital now gets. The distinction between private and public service providers apparently will be blurred. The removal of this two-tier public and private system is seen by many to be removing the advantage one can get from the co-existing private and public system. The public health care providers can serve many role and function, which any private provider cannot effectively take on. Vivid examples are emergency services, occasional or unusual treatment modalities (that may not bear good commercial viability), training and research. On the other hand, the private providers can provide a good reserve and additional flexibility of service. To remove this two-tier system will destroy all such advantage gained. It must be noted that facilitating communication and co-ordination between sectors of health care service does not necessarily require putting everything into one artificial sector.

Basic Philosophical Shift: Flexible Two-tier to Monopolistic One
29. The degree of control over the different health care providers by the single fund holder may be easy and direct. However, it is to be noted that this may be the wish of the one controlling, it may not be to the advantage of the general public, particularly in terms of choice. The Hong Kong public should be particularly aware of this basic philosophical shift in the health care service delivery structure: from the flexible dichotomy of a two-tier public and private system to a monopolistic absolutism of one system.

Compartmentalization: More Than One Reason behind it
30. Further comments on delivery system in the Harvard Report centered on the observations made in Hong Kong. It is observed that the different sectors of the health care services tend to work on their own. Co-ordination and communication between each are not sufficient such that the service provided to the patients can be fragmented. The term "compartmentalization" is being coined for this phenomenon. This is of course undesirable and steps should be taken to improve on this situation. However, it must be noted that this is not something that happens because of any one particular event or cause. Surely there are many reasons, each contributing in its own way, behind it. Insufficient communication and feedback are often quoted as one main reason for it, so is the significant price differential between the private and the public sectors.

More Than One Way to Solve Compartmentalization
31. Improvement on these areas certainly will help a lot in removing the so-called "compartmentalization" problem. Steps will be taken to address the communication problem. What is important to realize is that artificial integration of all sectors into one system is not necessarily the only or the best method to solve this problem?

32. The steps that may be taken include better patient information flow by taking advantage of the recent developments in technology, say patients' information smart cards that contain patients' information to be carried by the patients themselves and read by the attending physician whenever it is necessary. Perhaps before that can be fully implemented, establishing the culture of providing patient with sufficient information, say in the form of discharge summary, whenever a patient leaves the care of a practitioner is one good alternative to improve on the situation.

33. There are also suggestions for establishing good liaison system between the public and private sector as well as primary care and specialist-type practice. Programs based on such philosophy and objective have been implemented in limited areas. Such activities should be carefully expanded and extended. These will surely help to reduce the current "compartmentalization" situation.
Processes Only but No Health Target

34. Much of the Harvard Report has concentrated on the processes of health care financing and delivery. Little, if at all any, consideration has been given to health targets. We should have in mind specific objectives and yardsticks for the health status that we hope to achieve for our population to plan the processes of health care services. It is surprising that health targets is being missed out in a major deliberation of health care policy and system.

Challenges in Appendix One
35. Then there is the subject of quality assurance and monitoring the health care providers dwelt on at length in the Harvard Report. While there may be some truth in some of the comments, many of the assumptions, alleged factual basis and the reasoning made in the Harvard Report are being challenged. The bases of these challenged are being listed out in Appendix One of this Supplement.

Management and Assessment of Providers
36. Other than noting the challenges, it is important to set out suggestion for improvement. All systems require an eye for improvement at all time. As far as dispute resolution and complaints handling, it is understood that the Hong Kong Medical Council will be considering making their procedures more user-friendly, more transparent, more accessible to the general public and more accountable to the general public. This may include increasing the number of lay members in the Medical Council, requiring the presence of at least one lay member in any consideration by the Preliminary Investigation Committee.

37. Quality assurance programs are to be implemented both for private and public hospitals. It is understood that there will be arrangement for peer review of outcome indicators for hospital practices in both private and public hospitals. Accreditation of all hospitals, including private hospitals should be considered.

38. Quality assurance programs for practitioners should also be considered and implemented. It is being under consideration for certain professional advancement programs to be implemented in order to improve on the general practice standard.

39. Information to patients may be improved by having a definite and fixed information source. No doubt a patients' information registry may serve that purpose.

40. The establishment of an office of health services ombudsman is tempting. While it may provide a more comprehensive or quicker response to any institutionalized health care, it may indeed be taking up the role of the law courts under a different setting, thus complicating and overlapping with it. However, the establishment of a mechanism for quick and fast resolution of medical disputes or misunderstanding is something to be considered and explored.

Suggestions in Appendix Two
41. Detail program and/or suggestions for implementing the above objectives are being set out in Appendix Two of this Supplement.

Points stated in the Harvard Report
(1) Which are erroneous;
(2) Which are not providing a satisfactory consideration; or
(3) Which should not be accepted as presenting a fair description.

1. In the discussion for option models for health care financing, the Harvard Report has limited its consideration to four-and-a-half models. Further it has limited itself to discussing, in any useful or meaningful manner, to one option only, that of the Health Security Plan and Long Term Care Savings Accounts (Option D) which is the one option that obviously favoured by the Harvard Team. By limiting its discussion in such a manner, the Harvard Report is prejudicing a fair understanding and consideration by any reader of the report and ultimately a fair judgment amongst the various options.

2. The Harvard Report has failed to consider many other common options or combination of options in the issue of health care financing, thus greatly prejudicing the consideration and judgment for the final choice of options.

3. The feasibility of adopting any one particular option is considered on the basis of that option being used solely and in isolation. That is not a practical or meaningful way of discussion. Different options could have been used in combination. The advantage offered by one option could have been made use of to reduce or to ease the disadvantage of another option. Failure to give consideration or discussion in a comprehensive manner is most disappointing for a report of this nature and status.

4. Consideration has not been given to maintain the strength of the Hong Kong healthcare system (some strength has been pronounced by the Harvard Report itself). The important purpose of identifying the strength of any health care system must lie in keeping such strength. However, at no time did the Harvard Report express ways or means or indeed show any concern in maintaining the strength that it has identified. This is most surprising and unsatisfactory.

5. The Harvard Report itself agrees (under paragraph 1.5.1) the "Since resources are limited, every society must make trade-off in its health care system when pursuing multiple goals, such as equity, efficiency, quality and cost control. The benefits a society is willing to give up in exchange for other advantages will depend on its beliefs and values as well as on the prevailing political possibilities. The Harvard team worked with the Steering Committee to clarify the values underlying Hong Kong's desired health care system, and the following guiding principle emerged: Every resident should have access to reasonable quality and affordable health care. The government assures this access through a system of shared responsibility between the government and residents where those who can afford to pay for health care should pay." It is doubtful whether the Steering Committee could represent the value of the Hong Kong society without prior consultation. It is open to the public to question what is being represented in the report since the guiding principle is indeed the government's view only and not that of the society at large.

6. The guiding principle so adopted represents an ill-defined principle, which begs question in itself. It is obvious that different people have different views and at different times about what is reasonable and what is affordable. The guiding principle thus gives little practical indication or parameter.

7. If health care policy is an "exchange depending on beliefs and values", as stated in the Harvard Report, the possibility of a higher budget percentage for health care has never been considered or even mentioned. The Harvard Report is obviously working on a parameter that the government expenditure on health care must be kept at the current proportion. If that is so, then it should have been spelt out as the intention of the Harvard Report.

8. Though the report proclaims to be "evidence-based", its deliberation and reasoning do not fully support such contention. See as examples: paragraphs 4.2 and 4.3.

9. The claim of evidence-based approach is shattered by the following obvious faults:

a. The allegation of the Medical Council not allowing doctors to complain against other doctors was made without even verification with the Medical Council.

b. The allegations against the practice of doctors were mainly based on information obtained from focus groups, individuals, media reports and unscientific surveys of interested groups. The opinions and results are, as expected, biased.

c. There were not enough efforts in getting outcome measures of treatment. Clinical audits in Hospital Authority hospitals had not been sought and studied. Published territory-wide, audit reports of the Hong Kong College of Obstetricians & Gynaecologists was not even noticed. No survey had been undertaken on the opinions of patients who had received treatment in private clinics and hospitals.

d. There are reports from some members of the medical profession that quite a number of general practitioners did undergo much continuing medical education, which however were not well documented before the establishment of the Hong Kong Academy of Medicine.

10. There is much doubt about the factors, basic assumptions and base figures used in making projections and estimation for Hong Kong's future health care expenditure. Figures for years with significant capital expenditure during a period when there was rapid growth and expansion may distort or misrepresent the situation leading to wrong estimate.

11. Health targets in the form of what health indicators or disease prevention and management objectives have never been considered or discussed. The mode of healthcare services that received much discussion is still treatment orientated.

12. A Healthcare Security Plan contribution should indeed be considered to be a tax. It must be realized that the contribution percentage suggestion should be taken as the starting point only. It is anticipated that it will definitely increase quickly with rising expectation and more deliberate use of the system after contribution. Citizens should be aware of this: that this is a permanent and perpetual instrument for drawing contribution directly from citizens without the connotation of raising tax.

13. HSP serves limited use only: namely hospitalization, specialist outpatient services for certain serious chronic diseases. Primary care services financing provision has not been fully or satisfactorily provided for. Apparently it will be left for people's own direct payment.

14. Whilst the importance of primary care and/or family medicine have been recognized, no sufficient deliberation has been put into this vital area and no concrete proposal in any form has been made.

15. The MEDISAGE program is only one program providing limited service for limited time. The terminology can easily confuse and mislead citizens into believing that after their contribution to the fund, their old age medical problem and bills will be totally dealt with by this scheme. In fact, it is not. That misunderstanding should be clarified for the citizens to have a clear idea before they impart on their discussion and choices.

16. Competitive Health Integrated Systems are more of an operative model rather than a financial option. Though claiming to remove compartmentalization within the health care system, the effectiveness is doubtful. Indeed, it is more certain that it may give rise to overlapping of service and also compartmentalization between different integrated system itself.

17. Compartmentalization between different sectors of the healthcare system is a matter that has a structural basis. To address it one will have to consider the operative and fee charging structure of the current health care system. Failure to consider these matters will result in failure to solve the problem of compartmentalization.

18. The Consultants tended to use trivial matters to support their criticisms, such as referral procedures, reply to referrals, duplication of services and transfer of information. These can easily be improved by appropriate administrative means.

19. The following allegations are wrong and unjustified:

a. drug charge as significant portion of income
b. earnings of doctors as compared to other professions
c. doctors reluctant to criticize other doctors
d. difficult to obtain expert opinion
e. little recourse in case of poor treatment
f. lax disciplinary system

20. There is no study of medical manpower, services of allied health professionals, dental services and no consideration of the future practice of Chinese medicine.

21. There is little and insufficient consultation with various sectors of the healthcare industry. It has been revealed that only a handful of members of the nursing profession, the largest manpower source of the healthcare industry, were consulted in the compilation of the Harvard Report. It is doubtful whether other paramedical workforce, allied health professionals, e.g. the physiotherapist, the occupational therapist, were consulted.

Directions and Measures to be taken by
The Hong Kong Medical Association
For the improvement of health care services in Hong Kong

1. To inform and advise the public that

(a) it is the society's choice in the making of a healthcare policy;
(b) the public should get better informed on the subject, in particular, the options and alternative available;
(c) the government should better inform the public and allow more opportunity for the public to express their view on the matter;
(d) only when the public are better informed and be able to express their view can the values of the society be properly gauged;
(e) the value and choice of the society should not be dictated by the government, particularly when the public is not well informed on the matter (as happened in the compilation of the Harvard Report).

2. To support suggestions, proposals and advice on the maintenance and upkeep of the strength of the current system and to support changes made to improve on the current healthcare services of Hong Kong but not suggestions for changes without good and fair expectation of more advantages being gained than disadvantages being suffered (as judged by the values of the society).

3. To suggest, advise and persuade the government to:

(a) better inform and consult the public in the formulation of health policy, in particular the objectives and guiding principles;
(b) formulate health policy and/or review existing ones, if any, taking into account factors including, but not limited to, health targets, societal values (as evaluated after consultation with the public), demographic changes, and economic development;
(c) acknowledge the importance and necessity of delineating and/or defining the role and parameter of the government involvement, intervention and/or subsidy in healthcare services; and
(d) so delineate and define the role and parameter of the government involvement, intervention and/or subsidy in healthcare services.

4. To bring to the attention of the public and the policy decision authority the idea and opinion expounded in this supplement, in particular (but certainly not limited to) that consideration be given to:

(a) adopting a combination of various approaches (instead of limiting to one approach only in individual options mentioned in the Harvard Report) in devising new measures for healthcare financing;
(b) the importance of delineating the parameter of services that the government will involve and/or subsidize before a realistic/achievable objective of the government involvement in healthcare can be defined;
(c) the importance and relevance of establishing health targets in the process of setting health policy;
(d) recognizing the public and private two-tier organization is one important strength of the current system and to keep an adequate balance between the two-tiers;
(e) clarifying and/or redefining the meaning of "user-pay" to give effect to its potential contribution to health care financing when adopted in variations both in degree and extent;
(f) the importance of actively developing primary health care in Hong Kong;
(g) the importance of patients culture in the effective use and functioning of healthcare system and to take that into consideration when planning healthcare services.

5. To enhance availability and accessibility of health service information to the citizens by:

(a) considering and proceeding with, if possible, the establishment of healthcare services information registry;
(b) collecting, recording and conducting survey, within the resources capability of HKMA, information relevant to healthcare services; and
(c) enhancing availability and accessibility of healthcare service information to the medical profession so that they can, in turn, deliver such information to the public.

6. To enhance maintenance and improvement of professional standard by:

(a) considering and proceeding with, if possible, programs for improvement and/or maintenance of medical practices;
(b) organizing and coordinating, whenever and wherever feasible, professional standard enhancement activities, for example, continuous medical education program.

7. To enhance the doctor and patient relationship by:

(a) reforming the receipt and handling processes of the Enhancement of Doctor/Patient Relationship Committee (jointly held with the Consumer Council) to facilitate the handling of patients' complaint; and
(b) releasing regularly educational information on enhancement of doctor/patient relationship based on actual experience; for example, undesirable doctors' or patients' behaviour.

8. To improve confidence in complaint and compensation mechanism by considering and proceeding with, if feasible, the establishment of an Institute of Medical Expert Witness to allow a panel of medical expert witnesses to be available.

9. To improve on information flow between different sectors of the healthcare system by:

(a) exploring the technology and the practicality of the use of "smart cards" in the storage and carriage of patients' information;
(b) advocating the use of discharge summaries for both public and private hospitalizations;
(c) promoting exchange seminars and meetings between public and private as well as specialist practice and primary care doctors; and
(d) exploring the feasibility of patient information storage with Internet connection.

10. To explore ways and means of improvement on monitoring, auditing and accreditation mechanisms available for practitioners and institutions, e.g. hospitals by participating and establishing if necessary, local accreditation bodies.


Grateful thanks are due to the following individuals and institutions for their assistance in the collection of views of the medical profession on the Harvard Report:

Alice Ho Miu Ling Nethersole Hospital
Canossa Hospital
Caritas Medical Centre
Caritas Medical Centre Doctors' Association
Dr. Cheng Ngok
Dr. Lai Yau Shing
Glaxo Wellcome China Limited
Hong Kong Baptist Hospital
Hong Kong Sanatorium & Hospital
Pamela Youde Nethersole Eastern Hospital
Doctors' Association of Pamela Youde Nethersole Eastern Hospital
Princess Margaret Hospital
Doctors' Association of Princess Margaret Hospital
Queen Elizabeth Hospital
Queen Elizabeth Hospital Doctors' Association
Queen Mary Hospital
Queen Mary Hospital Doctors' Association
Ruttonjee Hospital
Ruttonjee Hospital Doctors' Association
St. Paul's Hospital
St Paul's Doctors' Association
St. Teresa's Hospital
Tuen Mun Hospital
Tuen Mun Hospital Doctors' Association
Union Hospital
United Christian Hospital
United Christian Hospital Doctors' Association

This supplement is available for the reference of the public through the City District Offices and the branches of Wing Lung Bank to whom we are grateful.

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