Time to change: Recommitting primary healthcare

Sophia SC Chan 陳肇始

HK Pract 2018;40:109-114

Good evening, it is my honour to be the orator of The 29^th Sun Yat Sen Oration of The Hong Kong College of Family Physicians.

We all know that Dr Sun studied medicine at the Guangzhou Boji Hospital and was one of the two graduates from the College of Medicine for Chinese (the forerunner of the University of Hong Kong). He earned the licence of Christian practice as a medical doctor. In 1911, he played a key role in the overthrow of the Qing dynasty. His life is legendary. But what turned him to a politician? In his own words, he saw danger ahead and everyone should fight against it together. With such belief, he pressed for a change.

I am glad to see Professor Rosie Young, Chairman of the Committee and Professor John Leong, also as a member of the Committee working on the report “Health for All, the Way Ahead” here in the audience. In his opening speech, Dr Angus Chan has rightly pointed out that the secretary for this report was Mrs. Carrie Lam. In fact, I started my journey in primary healthcare with my master degree at the University of Manchester, and I wrote my master thesis based upon this report.

At the time when I was in the field of nursing education, the focus of my thesis was on how to reorient the nursing curriculum for the betterment of primary healthcare system in Hong Kong. It seems a coincidence that the now Chief Executive, Mrs. Carrie Lam, and I are both committed to primary healthcare. Looking at our healthcare system in Hong Kong, the public healthcare sector is a safety net, providing 90% of our inpatient bed days and 29% of primary healthcare, or outpatient services as alternatively known. Whilst for the private healthcare sector, it provides about 10% of inpatient bed days and 71% of outpatient services.^1,2,3

Angus also mentioned resources. The government expenditure on health has been increasing since 2003, except for 2 periods (2004 to 2005 and 2005 to 2006). We are providing more and more resources, steadily, to support the provision of healthcare services to our people. In 2018, the government is generous and has increased such provision to 13.3% of the recurrent government expenditure on health, translating into some $71.2 billion.

There are 2 achievements by our healthcare system:

1. Universal access whereby “No one is denied adequate healthcare through lack of means”.
2. High efficiency.

If we look at our infant mortality rate, it is among the best in the world. Our life expectancy at birth was 81.3 years for men and 87.3 years for women in 2016.⁴ However, we are facing multiple challenges, especially a rapidly aging population and the heavy burden exerted by chronic illnesses; not to mention the emergence of new communicable diseases, increasing medical costs, advances in medical technology, increasing public expectations and health expenditure growing at a rate faster than our economic growth. For aging population, in 2012, elderly who aged ≥65 consisted of 14% (0.98 million) of our total population (7.15 million). In 2021, this will climb to 19% (1.46 million) out of some 7.63 million people and further to 27% (2.16 million) among those 8.01 million people in 2031. The life expectancy will also increase. By 2066, males will have a projected life expectancy of 87.1 years at birth, whilst 93.1 years for females. Our population is indeed aging very fast. From this graph, it shows how fast it is. It has taken France 100 years for its percentage of population with age >65 to grow from 7% to 14%. But in Hong Kong, it will just take 20 years.⁵ A population aging very fast brings lots of impacts, particularly on the utilisation of our healthcare services.

From the Hospital Authority’s (HA) data (inpatient service utilisation in 2010), the total inpatient days per 1,000 population increases drastically, starting from the age group 60 – 64. For bed utilisation rate, if we compare those aged under 65 with those aged 65 and above, the rate is 9 times more. It is projected that we shall need 2,100 additional acute and extended care beds in 2021 and 8,600 more at 2031. This is quite daunting.

If we look at the health burden imposed by chronic illnesses, malignant neoplasms, diabetes mellitus, diseases of heart, pneumonia and cerebrovascular diseases are some major causes of deaths in Hong Kong. They do exert a huge burden to our healthcare system. We all understand that for these chronic, non-communicable diseases (NCD), the key modifiable risk factors are smoking, alcohol consumption, obesity and physical inactivity. Despite they are personal habits somehow, from a public health perspective, we need to rectify such modifiable risk factors.

Just yesterday, at the Hong Kong Primary Care Conference, the Director of Health presented a report and illustrated some figures of a survey conducted in Hong Kong, as well as the global and Hong Kong’s action plan which we will be embarking on. Talking about smoking, particularly e-cigarettes, the government and the medical and health professions are on the same page, knowing the harm to health of e-cigarettes. We do not agree with the claim that e-cigarettes are less harmful for having less “toxic” substances. Having less toxic substances does not mean having less harm. All sorts of tobacco use, including e-cigarettes and the new heat-not-burn products, are harmful. There is also no evidence that these products are tools helping with smoking cessation. In such regard, the government is going to strengthen our regulatory framework. In doing so, there are a lot of factors to be considered and we are doing a lot of work internally. Given the recent developments, the voice of our medical fraternity is clearly heard. Considering a number of factors, including the latest evidence, we do not rule out the possibility for more stringent regulatory measures for these products.

Looking at the latest population health status revealed by the Department of Health (DH), you will see that Hong Kong people are in fact not that healthy. The latest population survey shows that unhealthy lifestyle and behaviours are rather common. For example, inadequate intake of fruit and vegetables, high salt diet, casual drinking, smoking, sedentary lifestyle, are commonly seen and all these are related to the 4 modifiable risk factors that I just mentioned. Obesity, hypertension, diabetes mellitus and hypercholesterolemia are common and the prevalence increases with age. Cardiovascular risk increases as the number of these conditions increases, for both men and women and particularly for the elderly. According to HA, in 2014, regarding the number of patients with chronic diseases per 1,000 population, it was observed that both “having 1-2 chronic diseases” and “having at least 3 chronic diseases” increased with age. The number of diseases and their complexity are seen to be worsen with age.

If we look at our healthcare system, particularly the public healthcare sector, long waiting time, packed Accident and Emergency (A&E) departments and crowded hospitals, beds overflown to corridors of our hospital wards are not uncommon. The problem is that our citizens still regard A&E as their first point of contact for healthcare services, making the waiting time at our A&Es even longer. Yet, among them, most cases are non-urgent or just semi urgent. So, what are we going to do?

All health ministers in the past have been working very hard to get through this maze and make changes, dating back to the Scott’s Report in 1985. I am sure that Dr Leong Che-hung is very familiar with these changes as he was once our honourable legislator and has been pushing for these healthcare reforms for years. In the latest document on healthcare reform “My Health, My Choice” in 2010 and the report on voluntary health insurance scheme (VHIS) published in last term of government, the healthcare reform direction is clearly laid, saying that we should enhance primary healthcare. Of course we also have other strategies, including promoting public-private partnership (PPP) in healthcare, developing electronic health record sharing system, strengthening public healthcare safety net and reforming healthcare financing arrangements. Among these wise counsels stated, the need for primary healthcare development is imminent. This is the first level of care at community level. It is ideally positioned to provide on-going care and support to individuals / families for their controlling of own health. Obviously, more resources should go to the community setting and we should re-focus our efforts on prevention as well as the continual management of chronic conditions. This is in fact nothing new.

Way back to 40 years ago, at the Alma Ata declaration (1978) by the World Health Organisation (WHO), there were several core principles of primary healthcare spelt:

• Community participation
• Intersectoral collaboration
• Integration of healthcare programmes
• Equity
• Self-reliance

At the Alma Ata meeting, it was stated that all governments should launch and sustain primary healthcare as part of a comprehensive healthcare system in coordination with other sectors. 30 years on, WHO published the World Health Report 2008, saying that rather than improving their response capacity, and anticipate new challenges, health systems globally seem to be drifting from one short term priority to another. There are always emergencies and crisis throughout the world, not only in Hong Kong, where resources are placed elsewhere, not injecting to develop primary healthcare. Above all, primary healthcare offers ways to organise the full range of healthcare services, from household to hospital, with prevention equally important as cure, ensuring that resources are invested rationally in different levels of care.

In another report published by the Lancet, titled “Alma Ata 30 years on (2008): Health for all need not be buried in the past”, if we just look at the title, it would seem that we are not doing very well, globally, not just in Hong Kong. Demographic and epidemiological transitions have strained healthcare systems, as new diseases emerge while the old remains. So, nearly 40 years on, what is the relevance of the Alma-Ata declaration in 2017? The answer is that we should revisit, review and refine our healthcare system.

Dr Donald Li and I were both at the World Assembly in August this year. I am happy to see that Dr Donald Li will be attending the 40 year Conference celebrating the Alta-Ata to be held in Afghanistan. Primary healthcare in the context of a wider healthcare system with community mobilisation and inter-sectoral action is very important. What the WHO envisioned globally when they talked about primary healthcare, is that not only the medical field, but the entire community could utilise social capital for development and health. Intersectoral action means different sectors would have to work together, not only health sector, but education, housing, environment, water and sanitation, nutrition and agriculture. Dr Leong Chi-hung, the key advisor, is actually working with the Kwai Chung District on some healthcare projects along these lines.

The report of the Working Party on Primary Healthcare “Health for all – the way ahead” (1990) chaired by Professor Rosie Young examined the primary healthcare system in place by then in Hong Kong. The key recommendations were to have stronger emphasis towards primary healthcare in policy making and to enhance primary healthcare services, with greater participation by the community, healthcare professionals and individuals. If we look at different studies after having gone through a comprehensive literature review, we can find lots of benefits due to primary healthcare on population health. To highlight a few, as follows:

• Better health outcomes. From previous studies, it showed that primary healthcare would reduce population mortality rates. The expansion of primary healthcare was associated with a greater reduction in all-cause mortality.⁶
• Better quality of care. Patient seeing primary care physicians reported a 9% higher score of perceived quality of medical care compared with those seeing specialists, even in a context of universal health insurance coverage and unrestricted physical choice.⁷
• Greater focus on prevention. Individuals living in area with a higher primary care physician supply were observed to be less likely to be obese.⁸
• Better management of chronic health problems. In a physician-led nationwide disease management programme held in Germany for patients with diabetes, there was a significant reduction in the occurrence of major complications of diabetes, e.g. myocardial infarction, stroke, chronic renal insufficiency and amputation of the lower foot. Also, the occurrence of at least one of the four major complication was lowered among those enrolled.⁹
• Reducing unnecessary specialist care. This is one of our major goals in promoting more primary healthcare. It was shown that a 7-day GP opening practice resulted in a 17.9% reduction in A&E attendance and a 9.9% reduction in unplanned (through A&E) hospital admission in weekends.¹⁰ Good primary healthcare actually helps reduce hospitalisation and alleviate disease burden.
• Good investment in money, as shown by a US study looking at Community Health Centres in US.¹¹

So what have we done in Hong Kong? A consultation report published in 2008 titled “Your health, Your life” showed that we have actually achieved a lot. In 2010, the Primary Care Development in Hong Kong Strategy Document set out the benefits of good primary care, major strategies and pathways of action to help deliver high quality of primary care in Hong Kong. In the same year, the Primary Care Office was set up, together with the Primary Care Directory, they aimed to promote the family doctor concept. The Primary Care Directory is an easily accessible electronic data base, containing practice-based information of primary care providers, including subdirectory for doctors, dentists and Chinese medicine practitioners. Apps and mobile websites were also launched in subsequent years.

The Hong Kong Reference Framework is another achievement. This is not possible without the hard work of the Primary Care Office of DH. Drawing international experience and global evidence of best practice, the documents provide a common reference to healthcare professionals for the provision of continuing and comprehensive care. They also aim for educating and empowering patients and carers by recommending evidence-based interventions. Reference Frameworks for diabetes care, hypertension care, preventive care in Children and Older adults are key examples.

Currently, there are multiple services introduced to enhance primary care including primary, secondary and tertiary prevention initiatives. Examples of these are: tobacco control, healthy diet in schools, eating more food and vegetables, colorectal screening, Primary Care Directory. Not only the DH, but the HA has also done a lot in providing primary healthcare, such as Community Health Care (CHC) and clinical PPP programmes for enhancing primary healthcare in the community. For Elderly Health Care Vouchers provided by the government, our Financial Secretary has given a one-off extra HK$1,000 in 2018/19 on top of the current HK$2,000 per year. The General Outpatient Clinic Public-Private Partnership Programme (GOPC PPP) will be expanding to all 18 districts in Hong Kong. The electronic health record sharing system (eHRSS), patient empowerment programme are also examples which facilitate the development of primary healthcare in Hong Kong.

What are we going to do during this term of government? There is a clear and strong commitment to primary healthcare as remarked in the 2017 Policy Address. With the strong support of our Chief Executive and our Financial Secretary, we will be doing more. We aim to strength primary healthcare services in the community as to enhance the overall health status of our people in Hong Kong, to reduce the hospitalisation re-admission and the use of A&E as the first point of contact. We aim to change this phenomenon. We hope to emphasize on preventive care and self-health management, and to address the need for a comprehensive and co-ordinated primary healthcare system in the community.

Two major initiatives were addressed. The first one is the setting up of a Steering Committee on Primary Healthcare Development to comprehensively review the existing planning of primary healthcare services, formulate a development blueprint and develop the model of district-based medical-social collaboration and the use of big data to identify areas of need in the medical and social services in the community. The second one is the setting up of the first “District Health Centre” (DHC) with a brand new operation mode in Kwai Tsing District within the next 2 years, aiming for commencing service in the 3rd quarter of 2019.

The Steering Committee on Primary Healthcare Development consists of many prominent members, including our WONCA President Elect, Dr Donald Li; Professor Samuel Wong, who is the outstanding award recipient today; Dean Professor Gabriel Leung; Dr Lam Ching-choi, Executive Council member and Chairman of the Elderly Commission; Mr. Chua Hoi-wai, Chief Executive of the Hong Kong Council of Social Services, Professor Cindy Lam, a key member of our Committee; and also representatives from the Labour and Welfare Department, the DH and the HA. We also have representatives from the Home Affairs Bureau. We have 3 core principles in the development of these DHCs:

1. Medical-social collaboration
We know that there is a lot of social problems that would affect our medical services, hence it is very important to get services to work together. I have been in very close contact with Dr Law Chi-kwong, Secretary for Labour and Welfare, to work on this initiative.
2. Community-based.
We have a District Council Chairman in our Steering Committee and have consulted extensively in the respective districts.
3. Public-private collaboration.
We are thinking of purchasing services from the community, rather than expanding HA nor DH to provide such services. We are trying to create a new model.

Kwai Tsing District is going to house our first DHC. As mentioned previously, there are a lot of work which will be embarked on by our Steering Committee on Primary Healthcare Development. We have 4 core sub-groups under the said Steering Committee. Dr Donald Li is reviewing the provision of healthcare by our government to see whether there is any necessary enhancement. Professor Frances Wong, Chairman of the Academy of Nursing, is looking at raising community awareness to reduce avoidable use of A&E and inpatient services. Dean Professor Gabriel Leung takes the task of big data analysis, identifying areas of medical and health services and Dr Lam Ching-choi is looking for room to enhance medical-social collaboration and working on an optimal model for pursuing primary healthcare in the community.

As briefed, our second important initiative is the building of DHC. As in 2017, we only have 2 years to do this task. The planned DHC will make use of the local network to procure services from organisations and healthcare personnel. In fact we have already met with a number of Family Physicians in the Kwai Tsing District and Dr Douglas Chan from the Hong Kong Medical Association (HKMA) is also in our working group. Other than Family Physicians, there are many healthcare professionals, e.g. nurses, physiotherapists, occupational health personnel, pharmacists, Chinese medicine practitioners whose services will be enlisted such that the public can and will receive their care in the community. After we have set up the first DHC, more will follow in other districts progressively, with the experience gained from this initial pilot scheme.

As you might have heard from the Director of Health yesterday, we have just recently published a report titled “Towards 2025. Strategy and action plan to prevent and control non-communicable diseases in Hong Kong”. This report houses the hard work of these past 2 governments under the NCD Committee chaired by the Secretary for Food and Health. We will continue encouraging the public to adopt a healthy lifestyle. The 9 targets set out are: reduce premature mortality from NCDs, reduce harmful use of alcohol, reduce physical inactivity, reduce salt intake, reduce tobacco use, contain the prevalence of raised blood pressure, halt the rise in diabetes and obesity, prevent heart attacks and strokes through drug therapy and counselling and improve the availability of affordable basic technologies and essential medicines to treat major NCDs.

In our DHC, we are going to work on reducing the risk of NCDs such as cardiovascular diseases, cancers, diabetes, chronic respiratory diseases. This is in fact the main focus of these centres. The initial conceptualisation of the potential client flow in these centres in the prevention and management of chronic disease are elaborated as follows.

As discussed within the working group and taking into consideration the suggestions from the Kwai Tsing District, we aim to have 5 satellite centres. The DHC network doctors (we are still working on the list of these doctors) will refer potential cases for chronic disease management to the DHC for multidisciplinary services. All in all, we hope to strengthen the prevention of chronic diseases.

Another potential flow for walk-in clients is that they can approach the DHC for basic and lifestyle assessment. After such assessment, if there is a need for medical consultation, they will be referred to physicians in the private sector. If there is a need for services by other healthcare professionals, they will be provided at the DHC. We of course cannot stop people acquiring healthcare services from the public sector, such as HA, but this is not our intended design. We encourage them to pursue services available in the community and in the private sector.

There is another potential client flow with a rehabilitation component. Now the HA is actually doing a lot of primary healthcare as well as community rehabilitation services. These actually constitute a very heavy workload for the HA. Some of these could be referred to the DHC. These are just some of the possible pathways for care provision.

In a nutshell, we want people to stay healthy in the community and avoid attending hospital as well as A&E unnecessarily. Family Physicians are to take care of the need of individuals and families, providing necessary care to them so that they would seek for secondary or tertiary services only when actual need arises. In recommitting primary healthcare, we hope to develop a system in the community. In fact, some kinds of primary healthcare are now being done by the HA, DH, private practitioners working in the community and various non-governmental organisations (NGO). We need to coordinate the system, whether it is a Primary Healthcare Authority or something else, we need an office to be the service planner for these services to glue the pieces together. I personally look forward to working together with you for a better primary healthcare system in Hong Kong. It is in the best interest of the Hong Kong College of Family Physicians to enhance and expand primary healthcare for Hong Kong.

Quoting from a paper published in The Lancet (13 Sept 2008), “health for all need not be a dream buried in the past, and the right to the highest attainable standard of health can be a reality within our grasp”. Finally, I would like to congratulate all the new Fellows and the awardees of the Outstanding Awards. A final word to the new Fellow is that; the future is bright, do stay in the public sector. I want to thank their parents as well. Without the support of family and friends, the achievements of our new Fellows would not be possible. I hope to be able to work together with everybody in the medical and health fraternity to promote primary healthcare and also to raise the standard of our citizen’s health, for the rest of my term in the government.