Research | Medicine and healthcare | 2019-09-10

Taking a big leap forward for primary healthcare development
More indispensable than ever amid population ageing in Hong Kong



The Bauhinia Foundation Research Centre (the Centre) today released the ‘Healthcare for All: Why and How?’ study report, which examines the obstacles and challenges faced in developing Primary Healthcare (PHC) services in Hong Kong, and makes recommendations on how to enhance the related services.

The prevalence of chronic disease in Hong Kong is of concern, with about three in ten Hong Kong people suffering from chronic diseases in 2016/17. Moreover, as the proportion of persons with chronic disease will rise significantly with age after 45, people with ongoing healthcare needs will increase in the face of the ageing population. In Hong Kong, we have an integrated healthcare system which provides different levels of care, from primary to secondary and tertiary. PHC is the first level of contact for people in the healthcare system, while the second and third levels are specialised and hospital based care respectively.  Well-developed PHC services focusing on prevention are most appropriate and essential.

Based on public hospitals’ data, the Centre roughly estimates that at least 40,000 hospital admissions of patients with high blood pressure, diabetes and influenza could be avoided in 2017. A comprehensive and effective PHC service enables patients with chronic illnesses to be managed in the community, encourages prevention before onset of diseases and thus reducing unwarranted hospital admissions. The Centre believes that developing quality PHC services is the ultimate solution to address the pressing healthcare needs of the population.

The Centre’s Director and Convenor of the study Dr Donald Li said, ‘Comparing with curative treatments, it is far more effective to promote public health by encouraging and enhancing preventive healthcare services. Also, shifting the paradigm to focus on community healthcare will help alleviate the pressure on public hospitals in the long run. Our study aims to strengthen PHC services in Hong Kong by recommending short-to-medium and long-term plans. We hope that the community and hospital services can be integrated, complementing each other in a community-based PHC services.’

Four pivotal factors and major obstacles to PHC service development

Since the 1990s, the Government has been trying to take forward the development of PHC services in Hong Kong. However, its efforts to shift the healthcare paradigm progressed at a snail's pace over the past 30 years, resulting from weak impetus of policy support. To provide a full picture of PHC development in Hong Kong, the Centre identifies four pivotal factors and major obstacles after studying information and data collected and conducting in-depth interviews with representatives from the medical and social welfare sectors, as well as service users:

The Centre believes that the Government and the community should overcome all these hurdles together. After analysing the study findings, the Centre makes seven short-to-medium term and long-term recommendations, and four complementary measures to boost the development of PHC services. Details of four major policy recommendations are as follows:

Short-to-medium term recommendations (5 to 10 years)

(i)     Launching a personalised ‘321: One Person, One Health Plan’ with subsidy

Engaging people to develop health-seeking habit and behaviours (e.g. regular health check-ups) at early stage is vital to identify health risks and reduce the risk of premature mortality due to chronic diseases. Nevertheless, only 37.6% of people received regular health check-ups in 2014/15, showing that a large proportion of Hong Kong people do not undergo regular health check-ups.

Aiming at enabling more Hong Kong people to adopt a self-care mindset and commit to health promotion and prevention efforts, the Centre suggests integrating the fragmented health check-up services into one-stop PHC services by introducing the personalised ‘321: One Person, One Health Plan’ (the Plan). The Plan will cover the checks of three hypers (hypertension, hyperlipidemia and hyperglycemia), screening of two cancers (the colorectal cancer and cervical cancer), and provision of one vaccination service (influenza vaccine). People aged 45 and above will be eligible for free enrolment after consultation with doctors. Undergoing health check-ups will facilitate early identification and timely intervention of people at higher risk of chronic diseases.

Upon completing the above health check-ups, individuals with health risks may need to receive further medical treatment or follow-up services with additional charges. The Centre proposes the Government to launch a ‘Community Continuous Care Plan’ to subsidise users as needed. The subsidy levels and limits for eligible participants can be formulated with reference to the existing screening programmes.

To encourage younger people to better manage their own health, the Government may consider introducing ‘Health Check-up Matching Subsidy Pilot Scheme’ along with the Plan. The Government may, for example, provide subsidies to people under 45 on a one-to-one pay ratio to incentivise them to receive regular health check-ups.

(ii)    Allocating resources for Family Medicine (FM) development and establishing a career path for community nurses

Family doctors are trained to provide comprehensive, holistic, continuous and preventive PHC to their patients and are regarded as the ‘gatekeepers’ of the health of every individual in community. However, due to insufficient resources to develop FM in the community and private sector, doctors are reluctant to receive FM training. As such, the Centre suggests the Government offer more incentives to encourage doctors to pursue further studies in FM, and provide more resources to organise induction courses and activities related to PHC in the community. These measures can enhance the safety and quality of services provided by doctors, thereby improving the efficiency and quality of PHC services and promote the building of long-term trusting relationships between patients and family doctors.

Respondents from the nursing sector noted that dispersed nursing positions and lack of organisational structure spark uncertainty in the career prospects for community-based nurses. Coupling with the lack of resources and effective support system, it is unfavourable to attract talent providing community-based services. In view of this, the Centre suggests the Government set standards for qualifications and experiences of nursing staff in the community, and establish a clear career path for community nurses. The Centre also suggests linking the grade structure of community nurses with nursing staff in hospitals, inspiring the ‘Revolving Door’ effect between hospital and community nurses. These arrangements can facilitate the flow of nursing talent between hospital and community. Each district can also offer full-time or half-time nursing jobs in accordance with the community needs, and deploy flexible arrangements to accommodate those who prefer working in-situ, attracting inactive nursing professionals to join the labour market.

(iii)   Encouraging broad participation in eHRSS and attaining 'medical record-following-the-user' goal

During the in-depth interviews, healthcare staff and the public also agreed that facilitating the eHR sharing between the public and private sectors brings about benefits for individual patients. However, two-thirds of private clinics still have not signed up eHRSS, of which the engagement is not proceeding satisfactorily. For members of the public, as at the end of June this year, about 1.06 million people have registered eHRSS, accounting for some 14% of Hong Kong’s population. Hence, there is plenty of room for advancement. The Centre suggests the Government require all medical practitioners and users to register eHRSS before participating in the public-private partnership programmes in future so as to boost the participation rate. Meanwhile, to ensure interoperability of current systems used by private healthcare service providers and the eHRSS, the Government should provide private clinics with adequate software and hardware support to improve their technical capability for updating and uploading health records.

Long-term recommendations (over 10 years)

(iv)   Establishing an independent ‘PHC Authority’ to enhance stewardship

Currently, there is no regulatory framework to steer, administer, monitor and evaluate PHC services. Furthermore, public and private healthcare service providers are regulated by different systems, which is not an ideal setting for collaboration. Taking into account that District Health Centres (DHCs) will operate on modes of public-private-partnership and medical-social collaboration, the Centre believes that the Primary Healthcare Office (PHO) can learn from the pilot experience of the Kwai Tsing DHC, and develop a comprehensive quality assurance framework in a bid to monitor and assess PHC services provided by public and private organisations. We recommend the PHO to continuously modify the assessment procedures, such as formulating assessment timetable, arranging release of information, as well as develop a systematic assessment framework for PHC services.

In the long run, the Government should further upgrade the functions of PHO by setting up a statutory ‘PHC Authority’ to administer PHC services and ensure continuous development. The Authority will be in charge of monitoring and evaluating the services provided by different organisations independently, as well as establish statutory regulatory procedures. The Centre further suggests by setting up this ‘PHC Authority’, the Government should allocate separate public funding for this PHC Authority.

Four complementary measures to meet needs of community and develop PHC network

The Centre also proposes four complementary measures, setting out a concrete and feasible strategic directions as well as action plans, including:

  1. Involvement of volunteers: Adopting the concept of ‘time bank’ for engaging volunteers at DHCs, in which individuals can accumulate volunteering service hours in exchange for healthcare services. DHCs can also provide volunteers with trainings by professionals (e.g. basic skill of blood pressure measurement) which can enhance their health awareness and knowledge in the process of helping others;
  2. Team collaboration: Devising a collaboration manual for multi-disciplinary teams so that the participating institutions and members of cross-disciplinary healthcare team can have a good grasp of their division of work as well as their roles. It can also help develop community-based services effectively. Besides, the Centre suggests setting up a trial run of self-evaluation mechanism at DHCs with a view to enabling team members to give feedback on services and coordination work;
  3. Review of ‘Primary Care Directory’: Reviewing policy objectives of the Directory and reasons for its under-utilisation in a bid to map out the development direction in the future. Apart from facilitating access to information of doctors, the Government can introduce more practical and diversified applications (e.g. online appointment system) for the sake of encouraging the public and healthcare practitioners to use the Directory; and
  4. Health promotion: Introducing a ‘Mobile Health Truck’ to offer PHC services such as basic health assessments and enquiry services, and public education activities with a view to increasing public awareness on disease prevention and health promotion through intensified community outreach.

‘Focusing on consolidating community resources is the key to the health reform, but the Government has to provide adequate resources to support this paradigm shift. In addition to the current funding mechanism, the Government should reserve sufficient fund to support the provision of quality PHC services, manpower and training in districts and ensuring sustainable operation of DHCs. All these are essential to accelerate PHC service development. Without the necessary resources and support, reform will only be empty talk. Investing in community may not bring immediate noticeable results, however, it will bring sustainable social benefits in the long run. The Centre aspires that members of the public can change their values and expectations about PHC services, appreciating a move towards shared responsibility between individuals, families, corporations, society and the Government. We believe that it will ease the mounting pressure on public healthcare system’, Dr Li concludes.

More information about the study report is available at our mini-site http://phc.bauhinia.org




Appendix

Full Report (Chinese only)
Executive Summary
Presentation Material