The role of Family Doctors in the healthcare system in Hong Kong – now and the future

Donald KT Li 李國棟

HK Pract 2017;39:107-110

Technological, cultural, and demographic developments are among the many factors that have a considerable influence on the practice of family medi c ine ; how the va lue of f ami ly medi c ine i s perceived; who their patients are; why they present to family doctors; and what they expect. Nonetheless health is about people – beyond the glittering surface of modern technology, the core space of every health system is occupied by the unique encounter between people who need services and those entrusted to deliver them.¹ As primary healthcare providers, family doctors make a difference in the health and lives of patients and their communities in a privileged way. Central to this is the unique depth and breadth of the family doctorpatient relationship as well as the care and comfort family doctors provide to patients.

In spite of its many strengths and sufficient financing provision at the moment, the healthcare system in Hong Kong is under great pressure. Ageing population, escalating healthcare needs and demands will pose a serious threat to the system’s sustainability and responsiveness. Furthermore, the present system is fragmented and not patient-centred.

International experience has found that no matter how much funding is available, healthcare resources will be exhausted if there is insatiable demand and indiscriminate use. In particular, we need to address the increasingly challenging issues which include rising morbidity rate for certain common diseases; limited and inadequate capacity to respond to changes in the demographic structure; under-development of preventive care; low health awareness among users; and the need for improving the quality of care in certain areas.

We need to introduce a new healthcare model with emphasis on Primary Care. How should we develop a new or reformed Healthcare Model in the Hong Kong context? What or who will shape the future of primary healthcare in Hong Kong? What should the future of primary healthcare system be? Should it be by Default; by Decree; or by Design?

By default, the practice of family medicine in Hong Kong will continuously be influenced by existing socio-cultural issues. Family medicine is western medicine practised in the context of a different race with a different culture. Hong Kong patients are recognised to have a particular pattern of health seeking behaviour. This includes the lack of the concept of family medicine; patients preferring to self-medicating directly by going to local pharmacies; treating medical consultation merely as a service, becoming more and more media-and-technology-savvy, instead of treating the doctor as a caring long-term health partner, thus have little appreciation of the importance of continuity of care. A lot of patients are symptom-orientated, placing values in the amount of medication received. They prefer doctor shopping, seeking secondary and curative healthcare rather than primary and preventive healthcare.

The present primary medical care system has been developed predominantly by private medical providers. While the Government employs the “money follows the patient” strategy, the supplementary primary healthcare services are publicly funded.

If we leave the present system unchanged, the future of family medicine will be shaped by default. Since the release of the Harvard Report in April 1999, the Hong Kong healthcare system has been under change in organisation and delivery. A healthcare system that attempts to place greater emphasis on communitybased primary healthcare is emerging. Family medicine practice has been proven to provide primary healthcare effectively to individuals and families,and its effectiveness is linked not just to the improvement of public health outcomes but also reducing costs. Thus the future of family medicine has been determined in part by decree in the Healthcare Reform.

Seemingly the commitment by Government to training more family physicians is a good by decree example. Nonetheless the future of family medicine shaped by the present decree has its shortcomings. With its effect on medical education, there is at present insufficient support for undergraduate family medicine teaching. We do not seem to see any prominence of Family Medicine Departments in universities despite the evolution of innovative new teaching methods which includes subject-based learning and problembased learning, mentorship programmes and teaching by family doctors in private practice. Although it is by decree, that a significant number of new medical graduates are channeled into family medicine training, the concern for budgetary deficits, uncertain career prospects as well as failure to re-allocate resources has posed a lot of strain on those organising family medicine training.

The future of family medicine should be by design to create an optimal primary healthcare that fits the demands and needs of the Hong Kong society. The design needs to find favour with the peers, patient groups, as well as policy makers and politicians.

For family medicine to meet peer expectations, there should be a career path that leads to a portable sustainable satisfying lifelong occupation with continuing longitudinal exposure to develop and promote the diversity of family medicine. The system must be enabled to the delivery of quality care. The length of family medicine training needs to be appropriate taking into account the duration and intensity. Family medicine in the private sector is different from that practiced in hospitals and the public clinics, trainees need proper exposure to private practice. There must also be sufficient family medicine consultant posts in hospitals to maintain the proper presence.

The design of family medicine for the future needs to address the hopes and fears of those entering into this specialty. Family physicians like all medical practitioners look for a professional life where there is growth, development and advancement of the profession. They look for professional fulfillment, and a healthy personal life with a sense of well-being and satisfaction with allowance for passion, security and autonomy. At present, common fears and threats experienced by the family physicians at large include the demands of a high level of patient contact, bureaucracy, the stringent accreditation processes, medical indemnity, rising costs to run private practices, cut throat competition as well as burden and stress generated from workforce/ manpower insufficiency crisis.

When we consider designing family medicine to meet patient expectations, we must understand that when a patient consults a doctor, he or she is looking for knowledge and predictions; wondering what is the diagnosis and whether with or without treatment the disease will go away. Family doctors have to be sensitive to what the patient is looking for during the medical consultation.

Very often, patients have a specific agenda when visiting the health service providers, which usually reflects concerns and problems they want the medical doctors to address during the consultation but may also include their desires for specific services. Patients’ expectations could be general and diverse but ultimately a test of the medical practitioners’ interpersonal and clinical skills.

Patients expect holistic care - whole person, comprehensive, continuous care/preventive care. Patients also expect innovative care which would include addressing problems of an ageing population, provision of chronic and terminal care, pain management, management of current public health threats such as A.I.D.S. and epidemic crisis. The care is also expected to be cost-effective. Today, medical practitioners have to work harder than ever before to stay at the forefront of their fields and to earn trust from their patients, because of the fast pace of changing public and patient expectations, perceptions with the fast evolving technology.

To meet the expectations of policy makers and politicians, the design of family medicine will centre on the gatekeeping role of the family physicians in the healthcare system, keeping patients from overburdening the hospitals, the cost-effectiveness, quality care and indicators of public satisfaction including patient satisfaction and public health outcomes.

To achieve the optimal design for family medicine for the future, we need changes including changes in the present healthcare system; changes in individual practitioners; and changes in patient and public expectations.

For changes of the present healthcare system, there is a need for our primary healthcare system to be more organised. The present primary healthcare registry needs to evolve to allow only those who have received structured training as well as showing a commitment to lifelong learning by engaging in continuous medical education to become registered.

A seamless healthcare system with public - private shared care needs to be built. What needs to be addressed is how to return patients back to the community after they have received adequate hospital care. To achieve this, information sharing will be most important (eHR is just one of the means of emerging technologies that can be leveraged on to improve the efficiency of healthcare delivery) and we need to keep pace with medical technology advancement. The mindset of our hospital-based specialist colleagues also needs to be changed.

A well designed future needs to incorporate changes in behaviour of individual practitioners. It is important to enable a holistic ‘teamwork’ approach with the establishment of interdisciplinary and multidisciplinary teams. The team should be led by family doctors and partnered with other healthcare workers such as nurses, traditional Chinese medicine (TCM) practitioners, dentists, pharmacists, physiotherapists and other health professionals in the provision of primary healthcare. The participation of allied health professionals is crucial and may be more cost-effective.

The future of family medicine in Hong Kong also depends a lot on the change in the healthcare economic and financial system. The best incentive for quality is reward and recognition. Unless family physicians can charge what they feel they are worth, low professional fees will become an obstacle to holistic care. The present fee-for-service system that neither values nor reimburses for the time and resources required for the holistic care must be changed. The escalating medical indemnity insurance posed upon family physicians is another concern that needs to be addressed.

The present healthcare funding should have in place purchaser and provider split model. There needs to be an individual unit responsible for public sector purchasing functions. This should include deciding on the scope and level of services to be publicly funded (e.g. quantities); the fee schedule (i.e. discount or subsidy rates) for different service types and user groups; the appropriate payment mechanism to different providers for different service types; and approving sub-contracting to the private sector. These purchaser functions and the provider or provider organisational functions should be independent entities.

A proposal to setting up of a Primary Healthcare Authority should be seriously considered to allow better forward planning and administration of primary healthcare in Hong Kong. This Authority can focus on population-based community orientated/patient-centred care, advise the Government on the strategic and policy directions, health standards, statistics and information collection, (manpower projection is a data-intensive activity and healthcare workforce planning is also extremely complex) etc.

Population based community orientated/patientcentred care is a paradigm that balances doctor's obligations to the individual patient with that of society at large. This is also care that integrates principles of community medicine and public health into the delivery of primary healthcare. Family doctors should act as the coordinator and facilitator working closely with other allied health professionals and specialists to provide quality and cost-effective care to patients in the community.

Whilst this model of healthcare will be our new direction in the primary healthcare system, our concern is the lack of understanding of the concept and the significance of the role and concept of family doctor within the society. The role of family doctors is to be the main drivers of an efficient primary healthcare system. There is however skepticism among some quarters of the community of the concept of family medicine and some may even see the need of a doctor’s referral to be an obstacle to their access to specialist care. Family doctors have to demonstrate to the public their role not merely as a gatekeeper but as a health partner for life by providing appropriate preventive care and treatment at early stages. This should help raise the awareness of the general public about the importance of primary healthcare. In essence, family doctors need to educate their patients on their health seeking behaviour, whilst meeting their expectations.

The future of family medicine in Hong Kong should be designed by the profession for the profession that will become the decree. It is desirable that the primary healthcare will be a future that is built by mutual support and delivered by a workforce of fortified family physicians with the right balance.

The Gove rnment ha s expressed suppor t for enhancing primary healthcare in Hong Kong since the healthcare reform in 2010. More primary healthcare development strategies that could benefit the public in the primary healthcare setting should be developed. These include supporting professional development and quality improvement of family doctors and strengthening organisational and infrastructural support for such changes would support professional development and quality improvement.

To enhance primary healthcare, there needs to be a sufficient workforce. Despite investment in manpower studies, there seems to be a lack of solid plans in workforce reform and manpower planning of the primary care workforce. At present, the Family Medicine Departments of medical schools of both universities are not funded at levels to permit best international practice, for example through the funded research and teaching networks in communities as in Australia and the United Kingdom. The majority of post-graduate training of family doctors is conducted by the Hospital Authority. Yet 70% of primary healthcare is delivered by private practitioners. It is crucial to involve private family medicine specialists in training family doctors. The total annual healthcare budget is allocated to the Hospital Authority which purchases services, and trains doctors; but they themselves are the sole provider. There is lack of transparency and competitiveness. There needs to be purchaser provider split as advocated. The training of other primary healthcare workers such as nurses, dentists, TCM practitioners and other ancillary primary healthcare workers is equally important.² Concurrently there should be more emphasis on team building and defining new roles of primary healthcare workers.

Changes in the career structure of family physicians will also shape the future of family medicine in Hong Kong. A career in family medicine can be quite diversified and can be structured according to the different stages of their lives. The career should include teaching, research, and service to the discipline such as work for the college as well as services to the community. There should be different priorities at different phases of the professional and personal lives of family physicians. In general, family physicians will be busy building clinical practices in the first ten years after they finish their training; however into the thirtieth or fortieth year, they may be more stimulated by research, teaching or even medico-legal work. Diversity will make their professional lives more fulfilling.

Achieving balance in one's professional and personal live is the key to well-being. The future of family medicine will ultimately depend on changes in individuals, i.e. medical practitioners themselves. The hardest thing however to change is to change oneself. Individual change needs to include the change in the care of the neglected self. Advocacy is required for family medicine to practise what they preach, issues related to proper nutrition, adequate exercise, work-life balance, a chance to pursue non-medical interests such as music or sports.

Over the past decade, Hong Kong has embarked on a journey of continuous improvement of its healthcare system. Developing a sustainable and responsive health system has been a clearly articulated goal. Chief Executive Mrs. Carrie Lam Cheng Yuet-Ngor has remarked earlier that in order to reduce the rate of hospitalisation and expenditure for caring for the elderly, the Government is prepared to spend more on primary healthcare, on preventive care, and on community and home-based care for the elderly.³ I hope that my recommendations can help realise the vision of the Government and family medicine will gain the public recognition it deserves.

Acknowledgement

This article is based on a plenary lecture given by Dr. Donald Li at the 40^th anniversary conference of the Hong Kong College of Family Physicians.