1. The Consumer Council provides its comments below in response to the discussion paper released by the Health and Medical Development Advisory Committee (HMDAC) of the Health, Welfare and Food Bureau (HWFB) entitled " Building a Healthy Tomorrow " regarding the future service delivery model for Hong Kong's health care system.
2. Reform of the health care system in Hong Kong can have great impact on consumers of health services. This submission sets out the Council's views as to the implications of the measures proposed in the HMDAC's discussion paper which have direct relevance to the interest of consumers/patients.
The Council's Views
3. The need for focus and co-ordination at all levels of the health system is a theme that emerges throughout the consultation process. The Council believes that the guiding principles to safeguard consumer/patient interests in relation to the proposed future health care model should be: Access, Quality, Responsiveness and Sustainability.
- Access: Equitable access to the health care system for all categories of patients should be assured.
- Quality: Services should be supplied with assured quality and in a timely manner.
- Responsiveness: A responsive system should develop ways to engage with individuals and the wider community receiving services to participate in decisions about services.
- Sustainability: Financial impact on patients/service users should be taken into account if changes are intended to be sustainable.
4. Flowing directly from these principles are some specific questions to reflect concerns that consumers/patients may have in relation to the future health care system. These include:
Health care financing - how would the implementation of the future model impact on the financial resources of patients?
5. The discussion paper quotes health spending statistics and states the HWFB projection that more than 50% of the tax revenue has to be spent on health care services by 2033. To facilitate comparison, the Council considers it is necessary for Government to present the percentages of both public and private health care expenses in terms of tax revenues and GDP in Hong Kong, and in other countries, in the coming financing consultation. Separate figures for public and private health care expenses will present a more accurate picture for comparison.
6. While there may be valid concerns about the growth in health care spending, the discussion paper does not address the issue of funding arrangements which are key elements in formulating Hong Kong's future services delivery model.
7. The Council believes there is an urgent need for debate on how the health care system is to be funded going into the future. The Council is of the view that the following key elements should be considered with the objective of ensuring that the health care system is developed to deliver a high-quality, accessible and equitable service for all:
- the method of raising health care funding;
- the level of health care funding; and
- the method of allocating health care funding.
8. To facilitate the public to have better understanding of the funding issue, Government should present information on an international comparation of the different types of health care financing models (e.g. funding resources from taxes, social/private health insurance, or out-of-pocket spending) and the pros and cons of each model as found in other comparable economies. This will allow the public to meaningfully participate in discussion as to which financial model/option our community supports.
9. Another important issue that warrants Government's careful consideration is the principle underlying the health care financing model to be adopted, whether the young and working will thereby be maintaining the old and the unemployed in the community by way of a financing model with reference to payroll, or whether they will be financing their own upkeeping. These are issues yet to be determined by Government in consultation with the community. Nevertheless, the Council is of the view that a desirable and sustainable health care financing model should aim at achieving equity as far as possible, i.e., one pays for own health care expenses.
Role of the public health care service sector - who should be eligible for public hospital services?
10. The issues of fairness in access and denying tax-paying patients not within the four target groups the opportunities to enjoy the use of public hospital services have raised much public concern. The Council feels that all patients should have access to high-quality health care services and that there should be no barriers, financial or otherwise, to receiving the services patients need, as far as possible.
11. From a pragmatic point of view, it would also be impractical to determine the kinds of services to be delivered by the public hospitals based on patients' income, considering the difficulty in carrying out means tests.
12. It is also of great concern the basis on which Government determines which groups of patients to be served and what types of illness to be treated by the public health care service sector. The Council suggests that clarification of eligibility in the use of public health care services and the role of the public health care service sector should be given particular attention in the current reform. Eligibility criteria should also be reviewed regularly to take account of changing needs.
Access to medical insurance - would all patients in need get medical insurance cover?
13. With public hospital services focussing on four target groups, people not within the target groups would need to turn to the use of private sector services and buy their own medical cover. The private sector should work with the insurance industry to bring about changes to benefit consumers.
14. This raises concern about access to health insurance for the elderly, people with mental and chronic illnesses. It is a widespread practice in the industry of trying to avoid those individuals who pose great risks to the insurers. If public hospitals are no longer available to all citizens who need the service, it is necessary for Government to take particular account of the needs of the disadvantaged groups and remove impediments to their access to private health insurance. The success of Government proposal to involve the private sector depends very much on access to private health insurance, i.e. whether the insurance industry can provide adequate medical cover at a reasonable cost to any person who needs it.
15. The Council believes the following issues should be addressed by Government, through regulation or agreements with the insurance providers, prior to repositioning of its role in the public health care service sector:
- clauses on pre-existing medical condition and critical illness exclusion, which will bar consumers from obtaining medical insurance cover;
- inability to secure/renew insurance coverage beyond the age of 65 or 70 (insurance companies often impose age limit to avoid providing coverage to older people) also hinders consumers' access to insurance at a time when they need medical protection most;
- difficulties for consumers to cross compare information from various insurance policies; and
- complaints from the insured on problems of claims.
16. Consumer affordability is important. In order to encourage consumers to take up private health insurance, Government may consider providing incentives such as giving tax rebate to private health insurance premiums.
Purchase of primary medical care service from private sector - would it enhance patient access and quality of care?
17. The Council welcomes efforts to explore the scope of the private sector to provide additional capacity and introduce more competition into the health care market.
18. However, the discussion paper lacks details on the arrangements, for instance, what type of services will be bought from the private sector, what patient groups would be served, and what objectives are to be met (e.g. percentage reduction in waiting time). It is important to disclose at an early stage:
- the role of the private sector, and terms of service agreement;
- level playing field - the selection criteria and process should be open, and fair to all qualified service providers;
- the standards - how to ensure standard of care from the private sector, need to introduce regular review of the arrangement (i.e. to identity whether it works and gaps, problems and areas for improvement); and
- how the review results will be made known to the public.
19. Patient's trust in the purchased service can be secured by guaranteed quality. Patients want to know that the service/care they are receiving meets agreed standards. It is therefore important for Government and the health care profession to put in place a system to monitor progress and systematically evaluate the quality, efficiency and effectiveness of services delivered through the private sector. Regular review of quality standards supports and encourages a culture of continuous improvement, and the system needs to be flexible and responsive to meet changing needs and priorities.
20. The development of specific service agreements with providers would bring greater clarity and accountability to the delivery of services. Performance indicators should also be introduced to measure outcomes against funding provided to private providers. The results and analysis of these performance indicators should be made available to the public in a way that will assist them to contribute to policy formation and come to a better understanding of the health-related services available to them.
Family doctor concept - is the proposed concept workable in Hong Kong?
21. The future model places a strong focus on developing the role of family doctors. The Council wonders whether the current health care infrastructure can be adequately developed to cope with the proposed change at the proposed timeframe. The routine day-time opening hours of many health services may encourage people to seek care at an inappropriate place, e.g. hospital A&E departments. There is also concern about cost implications in the use of family doctors.
22. Furthermore, it is unclear in the family doctor proposal as to whether patients must first go to family doctors before consulting specialists. If that is the case, this may have cost implications to patients and affect the extent to which the concept will be embraced by the public whilst consultation fees may need to be adjusted to make it more affodable. It is also doubtful whether consumers would stick to one family doctor, considering their reliance on word-of-mouth in choosing doctors and doctor-shopping practices.
23. Having said that, the Council believes that for the development of the family doctor concept, it would be necessary to ensure sufficient supply of qualified 'family doctors' to provide continuing and comprehensive and whole-person medical care to patients, on a 24-hour basis. The purpose is to protect and guide members of the public, so that they can be assured that service would be provided within reasonable reach of patients in need and that the professional treating them is fully qualified and competent. Commitment of individual practitioners is required and their professional organizations should take step to make that happen. Again, versatility of health insurance is required.
Development of primary and continuing care in the community - how would patients make their choice of doctors under the future model?
24. Regarding the proposal about promulgation of defined indications for use of public hospital resources, the HMDAC recommends the establishment of links and protocols with family doctors and 24-hour clinics to enable real emergency cases they refer to A&E to be attended to expeditiously. The discussion paper emphasizes the need for the development of primary and continuing care on a more integrated basis within the community with more structured links to specialized parts of the health system across the public and private sectors.
25. For the proposal to work, it is necessary to have smooth interface between the public and private sectors to help streamline the system and help avoid any potential duplication of effort, wastage of resources and delay in treatment to the detriment of patients. The Council considers that a framework may be needed to remove obstacles to integration such as an inadequate information system, insufficient or ineffective data and information sharing, professional inertia and administrative red tapes which may result in patient needs not being addressed in an integrated way.
26. A more fundamental issue is that patients may not know how to find the right doctor for the right treatment at the right price. One possible reason for consumers using public medical services instead of private ones might be the difficulty encountered in finding doctors with the right expertise in the private sector when not much consumer information is available or widely known to consumers. Government and the health care profession will need to address this issue when promoting private primary care.
The elderly, long-term and rehabilitation services - how would the quality of life for the elderly and particular care groups be improved under the future model?
27. It is noted in the discussion paper that the continued growth in the population of those aged 65 years and over will give rise to additional demands for health services, and significant development of these services is required as a priority to meet such demands. Many people with long-term illness, mental illness or disability experience a considerable reduction in their quality of life.
28. The Council is happy to see that the needs of these specific groups are given prominence in the discussion paper. In the case of the elderly, the emphasis is largely on requiring residential care homes to engage doctors to take care of their residents' primary medical care needs on a regular basis.
29. While welcoming this proposal, the Council considers that improving existing community facilities would help the elderly remain independent in their living environment through providing the necessary support and support for carers where appropriate. The Council is of the view that the elderly should also have the option of receiving care in their own home rather than in a residential care home (if that is practically viable given the physical constraints in our living environment). Providing improved assessment, community support and rehabilitation services to enable the elderly to remain in their own homes or community for as long as possible should be strengthened.
30. In relation to special needs (e.g. chronically ill children and rehabilitating patients), there should be increased community support and respite places, with the objective of helping patients return to normal life in the community. The Council considers there is a need for integrated multi agency services to support this approach.
Territory-wide medical record system - would it enhance the quality of care for patients?
31. The Council supports in principle the proposal of developing a territory-wide medical record system as developing a high-standard, well-integrated and reliable patient record system is central to quality health care. Notwithstanding the benefits of developing such a system, there are also potential threats to patients in respect of information security and privacy. It is necessary to ensure privacy safeguards (in addition to getting consumer consent for access) and mechanisms governing access, storage and retrieval of information from health organizations to address concerns about privacy and confidentiality. Patients would be very much concerned who would have access to their records, the circumstances under which access would be allowed, and whether their information would be passed on to other parties for purpose not related to the original collection of data. Furthermore, the issue of ownership of the medical record system should be explored by Government.
32. As a matter of freedom of choice, the Council thinks that participation from patient-end should be made voluntary. Individuals should be given opportunities to choose if they wish to build their medical history through the medical record system.
33. In the patients' interest, the Council asks the concerned parties to find ways to enable those patients who are non-computer users and would not be able to access the proposed electronic information system and those who choose not to participate in the system to pass on their records to other parties if necessary.
34. It also appears that the proposal is for access to medical record system by carers in both public and private sectors but there is no mention of patients' access. It is necessary to clarify whether patients, in appropriate cases, would be able to access their personal health information in the future system as well. The Council believes that allowing patient access would enable the patients to better manage their own health, but they would need assistance in understanding the health information in their health records and how much it would cost for them to retrieve information from the system.
35. The success of the system also depends on co-operation among health organizations to support the integration of patient record systems between the public and private sectors. Also, the adequacy of IT support is important to make the system work.
Participation of consumers/patients - how would the "voice" of the patient/service user be most effectively encouraged, supported, and reflected in the health care reform?
36. It is noted that three working groups have been set up to lead the development of the health care reform project. The Council considers there is a need for the health care reform to proactively engage consumers, patient groups and other stakeholder groups into the planning and discussion process as there is a role for these groups in the decision making process and a more structured and inclusive approach to community participation should be adopted.
37. The Council appreciates that public opinion can be voiced in response to the public consultation but permanent channels should be set up to capture customer feedback in a more structured way so as to provide an essential input to policy planning. Regular patient satisfaction surveys and systematic collection and analysis of complaints should be undertaken, alongside the existing complaint mechanisms. Such information should be made available to the public and considered in the decision-making processes.
38. The Council believes that increased involvement of consumers as partners in planning and evaluation is an important component in promoting openness and accountability of the future health care system.
Conclusion
39. Health is important for everyone. Personal and community health is the responsibility not only of Government and service providers of health care but also of individuals and community. The Council trusts that Government working in partnership with consumers and the community will help to improve the health status and achieve the health potential of the community. It is expected from the future health care system that
- consumers will have say in matters concerning their health, likewise patients with their treatment;
- patients know what is happening when they have to wait for services and receive treatment;
- patients do not have to repeat the same information on his/her health conditions 'over and over again' when moving between sectors in the health care system;
- patients will be provided with a high-quality, efficient and cost-effective service, whether directly in public hospitals or by arrangements with private hospitals;
systems and procedures will be more user-friendly, taking account of the needs of particular groups; - co-operation between public and private hospitals will be better developed to ensure a cohesive, integrated hospital system;
- funding will be more directly linked to service levels and there is much greater transparency in the planning, funding and delivery of services;
- greater opportunities for the community to participate in the decisions about health care services;
- everyone will have a fair opportunity to attain full health potential and, more pragmatically, no-one should be disadvantaged from achieving this potential;
- an action plan will be released for developing the initiatives further and a task force will be set up to oversee the implementation process.
