LegCo Paper No. CB(2)1771/96-97
(These minutes have been seen
by the Administration) Ref: CB2/PL/HS

LegCo Panel on Health Services

Minutes of Meeting held on Monday, 10 March 1997 at 8:30 a.m. in Conference Room A of the Legislative Council Building

Members present :

Member absent :

Members attending :

Public officers attending :

Items III and IV
Health and Welfare Branch
Mrs Maureen CHAN: Deputy Secretary for Health & Welfare (Acting)
Ms Jennifer CHAN: Principal Assistant Secretary for Health & Welfare (Medical)2
Mr Edward LAW: Assistant Secretary for Health & Welfare
Miss Manda CHAN: Assistant Secretary for Health & Welfare Department of Health
Dr Margaret CHAN, JP: Director of Health
Dr T A SAW, JP: Deputy Director of Health Hospital Authority
Dr KO Wing-man: Deputy Director (Operations)
Dr K K LAI: Senior Executive Manager (Professional Services)
Item IV
Hong Kong Overseas Medical Student and Concerned Students
Ms Maggie CHU
Ms Maggie CHUMs YIP Kam-siu
Ms Maggie CHUMr Jay KAY
Ms Maggie CHUMr Louis CHAN Yik-si
The Medical Council of Hong Kong
Ms Maggie CHUProfessor Felice LIEH MAK, OBE, JP: Chairman
Mr TSE Man-shing: Secretary, Head, Boards & Councils Office
The Hong Kong Medical Association
Dr LEE Kin-hung: President
Professor Grace TANG: Council Member
Mrs Yvonne LEUNG: Chief Executive
Dr CHU Kin-wah: Council Member

Clerk in attendance :

Mrs Mary TANG: Chief Assistant Secretary (2)4

Staff in attendance :

Mr LEE Yu-sung Senior: Assistant Legal Adviser
Miss Joanne MAK: Senior Assistant Secretary (2)4

Closed meeting

Open meeting

I. Confirmation of minutes and matters arising

Manpower shortages of nurses

II. Items to be discussed at the next meeting

III. Accident and emergency service in public hospitals and out-patient clinic service on public holidays

IV. Medical Registration (Transitional Provisions) Bill 1997

Discussion with the Administration and the Hong Kong Medical Council (HKMC)
Discussion with representatives of students and parents

Closed meeting

1. Members discussed and agreed that the anonymous letter received by Dr LEONG Che-hung in relation to the private practice by university medical consultants and specialists would not be circulated among members.

2. Members agreed on the topics to be discussed at the next regular meeting.

Open meeting

I. Confirmation of minutes and matters arising

(LegCo Paper No. CB(2) 1460/96-97)

3. The minutes of the meeting held on 13 January 1997 were confirmed.

Manpower shortages of nurses

4. At the Chairmans enquiry, the Director of Health (D(DH) ) reported that the survey report on the overall supply of doctors, nurses and auxiliary medical personnel in Hong Kong would be available in May 1997. Discussion on this item would be considered later.

II. Items to be discussed at the next meeting

(LegCo Paper No. CB(2) 1420/96-97)

5. The Chairman informed the Administration that the Panel wished to discuss the following items at the next meeting to be held on 14 April 1997 -

Private practice by university medical consultants and specialists;
Manpower problem of Siu Lam Psychiatric Centre; and
Primary health care.

With reference to item (c) above, the Clerk would inform the Administration shortly on the specific topics to be raised after collating members opinions.

Clerk

III. Accident and emergency service in public hospitals and out-patient clinic service on public holidays

(LegCo Papers Nos. CB(2) 1420/96-97 (01) and (02) )

6. At the request of the Chairman, The Deputy Secretary for Health and Welfare briefed the meeting on the measures which had been taken to ease the situation in the Accident and Emergency (A&E) Departments of public hospitals and to encourage the public to use the out-patient service provided by the Department of Health (DH) at the eight public holidays clinics (PHCs) during the Christmas and Chinese New Year (CNY) holidays. She reported that there had been an increase in the utilization of the out-patient service in PHCs during the public holidays. In the coming Easter holidays, DH would open these PHCs for three mornings and subject to the actual utilization rate would review the need on future opening hours of the eight PHCs. She pointed out that due to the restricted opening hours of the eight PHCs, the demand for primary medical service during long public holidays could not be expected to be totally met by the PHCs.

7. Mr Fred LI outlined the major findings in his survey report on the utilization of A&E service at the United Christian Hospital as against out-patient service at the Kwun Tong Jockey Club Clinic during the CNY holidays. He drew members attention to the following:

only two of the 132 patients using the A&E service in the hospital during the CNY holidays were emergency cases;
about 60 percent of survey respondents were aware of the MediLink hotline service but few of them had kept the information at hand; and
the manner in which the posters were displayed at the Kwun Tong Jockey Club Clinic was far from acceptable.

8. Given the high demand for medical service on public holidays and the shortage of manpower, Mr Howard YOUNG enquired whether DH and HA would collaboratively redeploy their existing manpower resources to facilitate the opening of PHCs throughout the long holidays. D(DH) replied that DH had been studying various options for better deployment of human resources with the aim of extending the opening hours of PHCs during long public holidays.

9. In the light of the Governments huge budget surplus, Dr YEUNG Sum queried why the eight PHCs could not open for service throughout the long holidays like the A&E Departments in public hospitals. D(DH) replied that additional resources had been applied for in the financial year 1997/98 for the eight PHCs to operate on all public holidays beginning with the long holidays in June and July 1997. Provided that there was sufficient part-time nurses, clerical and other auxiliary staff, new clinics would be opened progressively at locations in New Territories where the demand for medical service on public holidays had been consistently high.

10. Dr LEONG Che-hung was concerned that there were no new measures being proposed in the improvement of out-patient service in the eight PHCs. He said that PHCs should consider extending their business hours to cover the afternoon session when more patients were expected. While the exact cause of patients preference to use the A&E service in public hospitals had yet to be confirmed, he said the majority of the 132 patients in the survey did prefer to use the A&E service at United Christian Hospital rather than the out-patient service at Kwun Tong Jockey Club Clinic during CNY holidays because of the Hospitals 24-hour service and convenient access. D(DH) responded that the Department was not in a similar financial and administrative status as that of HA and it was not appropriate to make comparison with HA. With the additional resources available in the 1997/98 financial year, D(DH) anticipated that the eight PHCs could be opened for business on all public holidays. D(DH) added that any extension of these PHC service beyond normal business hours would be subject to staff consultation as well as the revision of the related terms and conditions of employment for part-time employees.

11. DD(Operations)/HA said the problem of increase in A&E attendance in public hospitals during long public holidays existed in overseas countries. While the actual causes in Hong Kong circumstances remained to be identified, he believed that the system of "Family Doctors" as adopted by some western countries could help alleviate the situation.

12. Mr Fred LI was disappointed that the information paper did not provide statistics on the utilization of the eight PHCs during CNY holidays nor did it propose measures to ease the extreme situation in A&E Departments during long public holidays. Referring to paragraph nine of the paper, Mr LI asked whether new PHCs would be opened in Kwun Tong district to meet the needs of the increasing population before the year 2000 when the new hospital in Tseung Kwan O would be operational. Mr LI was concerned about the inconsistency in the opening hours of PHCs during long public holidays as the public might be confused by such arrangement. In order to promote public awareness on the availability of primary health care service during long public holidays, he urged the Administration to liaise with HKMA for the further promotion of the MediLink hotline service and the provision of useful information leaflets to the general public. In response, The Administration assured that they would coordinate with HA for more effective and efficient provision of PHC service. D(DH) also undertook to approach HKMA to step up publicity on the MediLink hotline service. DD(Operations)/HA responded that redeployment of manpower resources had already been implemented within HA to ensure that emergency cases in public hospitals were handled in the shortest possible time. He added that patients not using A&E service out of an emergency nature would be subject to treatment under the Triage system. As for the statistics on the utilization of the eight PHCs during CNY holidays, D(DH) agreed to provide the figures to the Panel once it was available.

Adm
DH

13 Dr LAW Chi-kwong opined that there was an urgency in resolving the problem of inadequate medical service during long public holidays. In view of the fact that private practitioners shared around 85 percent of the total medical service in Hong Kong, Dr LAW was of the view that they should be encouraged to provide flexible and, if possible, longer hours of service on public holidays. As the demand for medical service in the afternoon was in general greater than that in the morning, Dr LAW urged DH to review the opening hours of PHCs with HA and report the findings to the Panel as soon as practicable. DD(Operations)/HA added that HA had already approached a number of medical associations with the aim of encouraging private practitioners to provide service in the afternoon session on public holidays.

14. In response to Administrations concern over the supply of sufficient part-time manpower for PHCs to operate throughout long public holidays, Mr Howard YOUNG suggested that adjustment of payrates should be considered for those categories of part-time workers in which recruitment difficulty had been identified. Mr MOK Ying-fan opined that the opening of PHCs throughout the long holidays should not be achieved at the expense of a lowered quality of service. Dr YEUNG Sum was inclined to believe that with better deployment of permanent manpower resources, the problem of insufficient qualified manpower to operate the PHCs on long holidays could be resolved. In response, D(DH) said that the factors contributing to recruitment difficulties were many. She assured members that DH and HA would examine all possible means to ensure the opening of PHCs on all public holidays and that they were manned by qualified personnel at all times. At the request of the Chairman, D(DH) agreed to provide the Panel with relevant information on the hourly rates of part-time workforce in PHCs.

15. Members in general agreed that DH and HA played different roles and functions in the provision of medical service to the community. As far as improving medical service on public holidays and in particular long public holidays were concerned, all agreed that DH and HA should coordinate their efforts and resources with a view to providing the best possible service to the public. The continuous implementation of proper publicity programmes on the availability of PHCs was equally important.

IV. Medical Registration (Transitional Provisions) Bill 1997

(LegCo Papers Nos. CB(2)1420/96-97 and CB(2)1444/96-97)

16. Mrs Selina CHOW tabled a paper summarizing her views and highlighted the following points -

the Medical Registration (Transitional Provisions) Bill 1997 (the Bill) did not seek to change the principles of the Medical Registration (Amendment) Ordinance (MR(A)O) 1995;
the Bill only applied to Hong Kong students who had been accepted to study medicine in the 38 recognized Commonwealth institutions before 1 September 1996, since these students had embarked on the studies based on the understanding that they would be granted the right of automatic registration in Hong Kong after graduation; and
the passage of the Bill would not affect the policy of requiring all overseas medical students, who launched on the courses after 1 September 1996, to pass the Licensing Examination (LE) as a prerequisite for registration in Hong Kong.

Discussion with the Administration and the Hong Kong Medical Council (HKMC)

Impact of the Bill on the public

17. The Administration reiterated that it encouraged a system of registration of professionals in upholding their standard of practice, as proposed by the relevant professional bodies. Based on this principle, the Administration had thus accepted the relevant recommendations put forward by HKMC in 1995, on the understanding that these could safeguard public interest and maintain professional standards of the medical sector in Hong Kong. Being one of the members of HKMC, the Director of Health (D/DH) added that MR(A)O 1995 aimed at imposing a uniform standard of assessment to ensure that registrations of medical practitioners were based on individual competence.

18. In response to a members concern about the impact of the Bill on the professional standard of the medical sector, the Administration explained that the passage of the Bill might lead to difficulties in assessing the standard and competence of the overseas medical graduates. The member opined that the Administrations reply had casted doubt on the standards of the 38 recognized universities. Mrs Selina CHOW also found the Administrations reply unacceptable because Hong Kong had all along been accepting graduates of these universities to register automatically in Hong Kong after they had completed their studies overseas. In response, the Administration clarified that it did not consider there was a sudden drop in the standards of these universities; but HKMC considered it necessary to set its own standards of assessment rather than rely on the General Medical Council of the United Kingdom (UK) for an indeterminate period. It was decided that a clean break from the previous policy was appropriate.

Limited registration

19. At a members enquiry, Professor Felice LIEH MAK explained that "limited registration" allowed graduates from any overseas countries to practise medicine in Hong Kong as long as he/she was employed by the Department of Health (DH), the Hospital Authority (HA), the Hong Kong University (HKU) or the Chinese University of Hong Kong (CUHK). The usual basis for employing them in the past had been based on professional expertise and general demand. Having offered employment, the employer was responsible for providing copies of applicants qualifications to HKMC. In other words, the graduate could not apply for limited registration himself/herself but would have to do so through the employer. She recalled that so far the Council had not rejected any applications. The Administration also confirmed that all students who had passed the Licensing Examination (LE) would be provided with internship placements in public hospitals.

20. In response to Mrs Selina CHOWs enquiry, D(DH) explained that the original purpose of limited registration was to bring in overseas medical professionals who had the expertise and knowledge required in Hong Kong at a certain time. Mrs Selina CHOW opined that the original intent of limited registration was not meant to facilitate the registration of fresh medical graduates trained overseas. The adoption of limited registration as an administrative measure to facilitate registration was merely used to circumvent the problems created by the introduction of MR(A)O 1995.

Administrative measures

21. Mrs Selina CHOW queried if the "administrative measures" being introduced could resolve the practical difficulties faced by the students for having to sit for LE and intern again in Hong Kong after completing their internship in their countries of training. The Administration replied that, with the administrative measures introduced, it would still be mandatory for the students to take LE if they wanted to register in Hong Kong. Once these students passed LE and completed the necessary internship, they would be able to register and practise in Hong Kong. There was no unfairness in the present registration system which was based on a uniform assessment. Furthermore, the administrative measures would help to facilitate the registration process.

22. D(DH) confirmed that the administrative measures would not exempt the overseas graduates from the requirement of internship in Hong Kong. However, she added that one of the proposed administrative measures was that the internship period could be shortened depending on individual performance.

GATS implications

23. Members noted that the reply from the Administration regarding the implications of the Bill on the General Agreement on Trade in Services (GATS) was still awaited. Senior Assistant Legal Adviser (SALA) advised that the Administration should clarify if there was any obligation for Hong Kong to observe articles VII and XVII of GATS.

Notification to students of MR(A)O 1995

24. A member enquired if the Administration and HKMC had ever promised in their replies to students enquiries that the students could be registered when they completed their courses. The Administration stated that it had not received any such enquiries. Mr TSE Man-shing said that no such promises had been made in response to written enquiries on the subject. There could be enquiries by phone, but no such record had been kept.

Granting of grace period

25. A member enquired about the basis upon which the 38 Commonwealth universities were recognized. In response, Mr TSE explained that the list of recognized universities was based on that provided by the General Medical Council (GMC). Therefore, when any of the universities was removed from the list drawn up by GMC, HKMC would follow suit, and no grace period had ever been granted by Hong Kong to the students of these universities deleted from the list. HKMC did not have any information about grace period being granted by GMC to the affected students to register in UK. At the request of the Chairman, HKMC would provide more information about the basis of recognition of overseas universities.

HKMC

26. Mrs Selina CHOW quoted the case of the granting of a five-year grace period to Hong Kong students in 1991 by GMC to illustrate that grace period could be granted when so warranted. She further read out from the letter of Professor LIEH MAK to GMC " ...that GMC owe the moral obligation to the current class of first year students who joined our courses in September 1990. There is the legitimate understanding that they would be graduating with full registration status with GMC..." The Chairman requested Mrs Selina CHOW to provide the letter for circulation to members.

27. Dr LEONG Che-hung pointed out that the case quoted by Mrs Selina CHOW was irrelevant. He explained that UKs policy of maintaining the position of Hong Kongs primary medical qualifications up to 1 July 1997 was in recognition of the status of Hong Kong as its colony prior to the handover of sovereignty. Hence, it had nothing to do with "grace period". The relevant correspondence between Dr LEONG and GMC would be circulated to members.

28. A member asked why MR(A)O 1995 commenced operation on 1 September 1996 when the Ordinance was passed in 1995. Mr TSE explained that the commencement date was set taking into consideration the time required for the preparation of the first LE which was held in September 1996. The member further asked if the standards of the 38 universities had been one of the factors considered by the Administration in passing MR(A)O 1995. Mr TSE replied that HKMC had actually no information on the standards of these 38 overseas universities which were assessed by GMC. The member asked if it implied that HKMC had blindly recognized the 38 universities if it had no information on the standards of these universities. Mr TSE explained that it was laid down in the then Medical Registration Ordinance (MRO) that graduates registrable with GMC were accepted to register in Hong Kong without the need to take any licensing examination.

Discussion with representatives of students and parents

29. Referring to the letters tabled, a representative of parents pointed out that the School of Postgraduate Medical Education and Training of HKU had still informed a student in July 1995 that the 38 promulgated universities were recognised by HKMC. The representative also elaborated on the following, which suggested that there was unfairness in the passage of MR(A)O 1995 -

The exemption of local medical graduates from taking LE showed that there was discrimination between local and overseas medical students, even though the latter were also Hong Kong residents;
the lack of consultation with the concerned students in amending MRO in 1995 was a serious blunder in the legislation process;
the allegation that affected students were trying to create privileges for themselves was groundless. She pointed out that these students were working hard to meet the requirements of MRO which, however, had been subsequently amended without their knowledge; and
based on the legal advice sought, none of the proposed administrative measures could help to resume the right of automatic registration for the affected students unless the MR(A)O 1995 was amended.

30. The representative further quoted another reply from HKU on 22 September 1995 which stated that "legislation as it stands, medical degrees from Australian universities are still registrable in Hong Kong." However, members noted that the same reply had also stated that "Overseas medical graduates who expect to complete their internships by June 1996 would be able to apply for Hong Kong Medical Council full registration. Those interns who expect to complete their internships beyond that date would be required to take the Licensing Examination". (A copy of the reply was circulated to members vide LegCo Paper No. CB(2)1497/96-97.)

31. A representative of students said that neither he nor the university authorities overseas had been notified about the MR(A)O 1995. He also pointed out that there were many practical problems with "limited registration". One common problem was that the overseas medical students simply could not find employment in the local public hospitals as many of them were worried that the students might not be able to pass the LE. He said that HA, in fact, had indicated preferences to appoint local graduates who could be appointed as doctors with full registration.

32. The representative pointed out that it would be administratively difficult for a hospital to handle the vacancy arising from the one-year internship of a student under limited registration. Furthermore, he criticized the LE for lacking in transparency and expressed concern about the low passing rate of 13.69% and the passing mark being set at 90.

33. Another representative of students told members that he had been informed by HKMC that the old policy remained intact in September 1995. He was made aware of MR(A)O 1995 only in February 1996. Then he was offered employment by CUHK to be effective on 1 July 1996. However, he was subsequently informed that he would not be granted provisional registration nor could he be automatically registered upon the commencement of MR(A)O 1995 on 1 September 1996. As a result, the representative had to return to Australia to take up non-medical jobs. At the request of the Chairman, the representative would provide supporting documents to the Panel. Professor LIEH MAK clarified that the representative had actually applied for an internship placement in CUHK in July 1996. Thus, he was not qualified for registration in Hong Kong then.

34. A representative of parents told members that her daughter had been sponsored for her overseas medical studies on the condition that she had to return to practise in Hong Kong after graduation and failing that, she would have to compensate the Hong Kong Government by $1,000,000. She asked whether her daughter was still obliged to compensate the Government if she failed in LE and therefore could not practise in Hong Kong.