Is the proposal of a ‘Primary Health Care Authority’ worth revisiting?

Lam Tai Pong 林大邦

HK Pract 2018;40:41-42

The Chief Executive, Ms Carrie Lam, identified primary healthcare as a major focus of attention in improving the healthcare services of Hong Kong in her maiden Policy Address delivered in October last year. She undertook to set up a Steering Committee on Primary Healthcare Development to comprehensively review the existing planning of primary healthcare services and draw up a development blueprint.

Its work will include drawing up a model for district-based medical-social collaboration, using big data to identify the areas of medical care services requiring in-depth study, establishing a framework to implement measures on disease prevention in a more systematic manner (e.g. vaccination), disease screening and identification (especially chronic diseases such as stroke) and strengthening scientifically proven service provision and policy-led development work. By World Health Organization’s definition, these are predominately primary healthcare services.¹ As family physicians, the daily clinical primary care / family medicine service we provide to our patients is a subset of this primary healthcare review.

Ms Lam reminded us that together with Professor Rosie Young and other members of the Working Party on Primary Health Care, she also once set out a blueprint for the delivery of primary healthcare in the early 1990s. There were many excellent recommendations made by the Working Party and were subsequently adopted, particularly on health promotion and disease prevention, for example, immunisation and surveillance which have improved primary healthcare in Hong Kong. However, limited impact has been seen on the delivery of clinical primary care service to the very many people in Hong Kong. Another major recommendation of the Working Party on the setting up of a Primary Health Care Authority was also never properly deliberated and has been essentially forgotten. What were the reasons behind it? A quarter of a century later, the same exercise is starting again. What can we expect this time?

Before looking forward, it is worthwhile to review what is happening in our healthcare system in order to appreciate the problems confronting us.

Hong Kong is currently spending 5.7% of its GDP on healthcare which is much less than other developed countries, for example, USA 17.9%, Australia 10% and UK 9.9%. About half of our healthcare spending is on the public sector but nearly 90% of this goes to hospital services with minimal support for primary healthcare. This contrasts with other places where the government provides strong support for primary healthcare, for example, Australia spends about 40% of its recurrent healthcare expenditure on primary healthcare, almost the same as for its hospital services.²

Hong Kong enjoys some of the world’s best healthcare indices, e.g. life expectancy of 87.3 years for women and 81.3 years for men and infant mortality of 1.5 per 1000 registered live births. What is facing us however is the direct consequence of some of these wonderful healthcare achievements, and something that is unparalleled in the history of healthcare delivery in Hong Kong. Our elderly population will increase at a rate rarely seen in this world before. Our over 65 will increase from 1.27 million in 2018 to 2.57 million in 2044, representing 17.0% and 31.4% of the total population respectively. In addition, over 85 will increase at an even faster rate of 2.6% (0.19 million) of the total population in 2018 to 7.5% (0.62 million) in 2043.³ As healthcare professionals, we know the healthcare need of an 85-year-old is manyfold that of a 65-year-old. The demands on healthcare services are likely to outstrip what our hospitals are able to cope unless communitybased healthcare services are substantially expanded to take up a significant share of the increase in demand.

There are also additional clinical implications. Any experienced primary care physicians would acknowledge that attending to one of their long standing elderly patients, especially over 85 years old, is very different from seeing someone of similar age for the first time. Their threshold of referral is likely to be much lower if one of these new elderly patients presents to us looking unwell. The late Barbara Starfield in her lifelong work argued that healthcare outcomes are closely related to primary care development.⁴ If that is true, Hong Kong should be having one of the best primary care developments in the world that enable us to achieve such impressive healthcare outcomes. I don’t really have the answer for this but what I do know is that we have a very hard working primary care workforce, many of our primary care physicians are providing morning, afternoon and evening service to their patients, often 7 days a week. Where do we find such work ethics in other parts of the world? Our hard working primary care physicians must be making a significant contribution to our outstanding healthcare indices and should be recognised for their dedications in serving their patients tirelessly.

At the University of Hong Kong, the teaching of Family Medicine and community-based care has been significantly enhanced. Since 2016, we have established a 7-week Family Medicine Community Care clinical clerkship for final year medical students to facilitate an adequate exposure to community-based care. The duration of the study is the same as other major clinical disciplines, e.g. Medicine, Surgery, Obstetrics and Gynaecology, and Paediatrics in the final year. Literature has showed that one of the best ways to attract students to join the clinical discipline is to provide an interesting and rewarding undergraduate training experience. We are therefore aiming to produce medical graduates who will have a good knowledge and understanding of community-based healthcare services. We are hoping that many of these young doctors will have an interest to join the other primary care physicians to serve our patients in the community. However, the infrastructure of providing good primary healthcare service will require a strong support from the Government. Is the Government going to deliver?

A quarter of a century is a long time. It represents about half of the working life of most individuals. Hong Kong must catch up in the delivery of our primary healthcare service since Ms Carrie Lam last set out her blueprint for the delivery of primary healthcare in the early 1990s. Otherwise, we will continue running the risk of our hospital service stretching to its limit with the yearly winter ‘flu surge’ followed by summer ‘flu surge’ until a major crisis which paralyses the whole healthcare system.

We must get ready for the future. We cannot afford to be unprepared for the upcoming healthcare needs of our population as healthcare planning takes many years of preparation. Is the provision of clinical primary care service by both Hospital Authority and Department of Health the best option for Hong Kong? How can duplication of service, i.e. wastage be minimised?

With the incorporation of Government’s General Outpatient Clinics under the Hospital Authority in 2003, the term “Hospital Authority” has in fact been a misnomer. Can we expect the “Hospital Authority” to pay equal attention to both hospital and primary care clinical services? Good hospital service is possible only if there is an equally good primary care service as a foundation to support it. Is the Government really committed to improving the healthcare of its people? Will a “Hospital and Primary Care Authority” be better suited for the future needs of Hong Kong?