LegCo Paper No. CB(2)1769/96-97
(These minutes have been seen
by the Administration)
Ref: CB2/PL/HS

LegCo Panel on Health Services

Minutes of Meeting held on Friday, 21 March 1997 at 8:30 a.m. in Legislative Council Chamber

Members present :

Members absent :

Member attending :

Public officers attending:

Health and Welfare Branch
Mrs Maureen CHAN: Principal Assistant Secretary for Health & Welfare (Medical)1
Miss Manda CHAN: Assistant Secretary for Health & Welfare
Department of Health
Dr Margaret CHAN, JP: Director of Health
Hospital Authority
Dr E K YEOH, JP: Chief Executive
Dr Susan CHAN: Deputy Director (Operations)
The Medical Council of Hong Kong
Professor Felice LIEH MAK, OBE, JP: Chairman
Mr TSE Man-shing: Secretary, Head, Boards & Councils Office
Hong Kong Overseas Medical Students and Concerned Parents
Ms Maggie CHU
Ms LAU Fung-yee
Mr WONG Tai-hung
Miss Elaine Y L CHOW
The Hong Kong Medical Association
Dr LEE Kin-hung: President
Dr CHU Kin-wah: Council Member
Professor Grace TANG: Council Member
Mrs Yvonne LEUNG: Chief Executive

Clerk in attendance :

Mrs Mary TANG: Chief Assistant Secretary (2)4

Staff in attendance :

Miss Joanne MAK: Senior Assistant Secretary (2)4

Discussion on the Medical Registration (Transitional Provisions) Bill 1997 (the Bill)

GATS implications

Discussion with the Hong Kong Medical Council (HKMC)

The Consultation Process
Overseas internship
Licensing Examination (LE)
Implementation difficulties

Discussion with Hong Kong Medical Association (HKMA)

Discussion with representatives of students and parents

Limited registration

General discussion

The way forward

Discussion on the Medical Registration (Transitional Provisions) Bill 1997 (the Bill)

(LegCo Paper No. CB(2)1576/96-97)

GATS implications

At the invitation of the Chairman, the Senior Assistant Legal Adviser (SALA) confirmed that the transitional provisions accorded to the Hong Kong permanent residents who hold United Kingdom and Commonwealth medical qualifications was not related to international trade in services and therefore fell outside the scope of the General Agreement on Trade in Services (GATS). Furthermore, since Hong Kong had not committed to the obligations under Article XVII of the GATS regarding the national treatment, he was of the view that the provisions of the Bill did not contravene Hong Kong's obligations under GATS.

2. Mrs Selina CHOW drew members' attention to the reply from the Secretary for Trade and Industry who had concluded that the Bill was not related to international trade in services and hence fell outside the scope of GATS. She also referred to the reply from the Secretary for Health and Welfare who confirmed that the Bill would not have any GATS implications.

Discussion with the Hong Kong Medical Council (HKMC)

3. Professor Felice LIEH MAK reiterated that HKMC was against further legislative amendment to the Medical Registration Ordinance (MRO),Cap 161. She emphasized the need for the removal of preferential treatment to any particular overseas institution and the requirement for all overseas medical graduates to sit for the Licensing Examination(LE), irrespective of where they receive their training.

4. She also stressed the need to uphold the standard of medical care to the general public. She highlighted the following points regarding the uniqueness of medical care in Hong Kong which accounted for the requirement of local experience for medical doctors to practise in Hong Kong -

Both the Hong Kong University (HKU) and the Chinese University of Hong Kong (CUHK) had been continually updating their medical courses to meet the changing needs of the general public. There had been increased flexibility in meeting local needs because there was no longer a requirement to adhere to British standards in medical practice.
There are a number of diseases like periodic paralysis related to thyrotoxicosis and naso pharyngeal cancer which are more common in Hong Kong. The type of treatment and the dosage of medicine given to local patients could be very much different from other countries.
Doctors have to be familiar with how local patients communicate their symptoms and how to communicate with local patients.
Most local patients were not as knowledgeable about medical care as compared to patients of western countries.
The system of medical care and the resources allocation system in Hong Kong were very much different as compared to other countries.
The volume of work undertaken by medical doctors in Hong Kong were much more than their western counterparts. There was hence a need for medical doctors to have local experience in dealing with heavy workload and at the same time provide quality service before practising in Hong Kong.

5. Professor LIEH MAK also explained some of the technical difficulties brought about by the proposed scheme under the Bill -

If the Bill was passed, the system of recognition of overseas institution would be reverted to the previous regime which was based on that provided by the General Medical Council (GMC). As a result, any changes made by GMC would affect Hong Kong's recognition of overseas institutions and would further complicate the system.
Problems were envisaged with those medical students who had enrolled in recognized institutions prior to the commencement of the Medical Registration (Amendment) Ordinance 1995 (MR(A)O 1995) but were unable to qualify for their medical degrees for a prolonged period of time. The transitional provisions would therefore have to be maintained for an extended period of time.
As the provisions of the Bill were confined to Hong Kong permanent residents, contentions might arise from those who were no longer Hong Kong permanent residents upon their return.

6. In response to the remarks made by Professor LIEH MAK, Mrs Selina CHOW pointed out that these were irrelevant to the proposed Bill which merely sought to give transitional provisions to a group of medical students whose interests had not been looked upon the passage of MR(A)O 1995. She made the following clarifications -

The Bill would only apply to students accepted by one of the 38 recognized institutions prior to 1 September 1996 when the MR(A)O 1995 came into effect, and who had not had the experience necessary for registration as of that date. Hence any changes in the recognition of overseas institutions by GMC would not have any effect on the implementation of the Bill.
Cases of medical students who were unable to qualify for medical degrees for a prolonged period of time were rather rare.
The Bill had specifically stated that it would only apply to those students who were at the commencement of the MR(A)O 1995 Hong Kong permanent residents in accordance with the law in force at the time.

7. Regarding (c), the Senior Assistant Legal Adviser (SALA) confirmed that the application of the Bill would be confined to those students who were on 1 September 1996 permanent residents of Hong Kong. Any subsequent changes in the definition of "Hong Kong permanent residents" would not cause any legal difficulties on the implementation of the Bill.

The Consultation Process

8. Mr TSE Man-shing detailed the following events in explaining how the public was made aware of the introduction of the MR(A)O 1995 -

January 1992 - the Medical Council disclosed to the media that a Universal Licensing Examination was forthcoming. At that time, it was envisaged that the first such examination will be held in 1995. The news was widely publicised in the local press.
March 1994 - local newspaper revealed that an Amendment Bill of the MRO would be introduced in July 1994.
7 April 1994 - the then Medical Council Chairman met the media and informed the progress of the law amendment and, among other things, the introduction of a Universal Licensing Examination.
9 April 1994 - the matter had been publicised in Australia by the Sing Tao Newspaper (Australian edition) and arising from it, the Medical Council received an enquiry from a doctor in Australia.
Between April to May 1995, the Medical Council received written enquiries about possible changes in medical registration. In reply, they were told that the relevant law amendment was in progress.
17 May 1995 - a press release was issued when the Medical Registration (Amendment) Bill 1995 was introduced, and the issue was widely reported by the press for a period of time.
Following the passage of the Bill, the Medical Council arranged for the release of a press statement with regard to the details of the new registration system and the Licensing Examination, which were expected to take effect in August 1996. The matter was publicised in the local press.
Between November and December 1995, the Medical Council received enquiries on the issue from students in Australia. They were told about the new arrangements.
The Medical Council also communicated the same in writing to all its overseas counterparts. Press statement about the Licensing Examination was issued in the United Kingdom with the assistance of the Hong Kong Government London Office.
1 September 1996 - the relevant provisions in the Medical Registration (Amendment) Ordinance 1995 finally commenced operation.

9. At the request of members, the HKMC would provide details of the consultation process and the letter which was sent by HKMC to the Hong Kong Office in London.	HKMC
10.As regards members' query that students had not been well informed about the removal of automatic registration provisions, MR TSE replied stating that students who have enquired through the HKMC were being made aware of the legislative amendment. He could substantiate his statement by providing replies given to students by HKMC	HKMC

Overseas internship

11. On the concern about overseas internship, Mr TSE informed that HKMC had assisted 4 students (one from Ireland and three from Australia) to obtain overseas internships. HKMC was not aware of any medical student who was unable to obtain internship in the country of training. He referred members to a letter from the Queensland State Office, Australian Agency for International Development indicating that, in view of the legislative amendment, Hong Kong medical students were now permitted to undertake their internship in Australia on condition that they would return to Hong Kong upon completion of their internship. At members' request, Mr TSE agreed to write to the Australian authorities to seek clarification if this policy was applicable to the whole Australia.

HKMC

Licensing Examination (LE)

12. In reply to members' queries about the LE, the representatives from the Administration, HKMC and Hospital Authority explained as follows -

There was no quota in the number of candidates passing the LE. Those who have demonstrated that they had the knowledge and clinical experience would be given a pass mark.
The LE consisted of three parts, namely-
Part I - multiple choice questions
Part II - test of English
Part III - clinical examination
Applicants would have to pass Parts I and II before being allowed to take Part III. A negative marking system was adopted for Part I where marks would be deducted for incorrect answers.
The multiple choice questions were drawn from a pool of questions which were used in HKU/CUHK examinations for third and fourth year medical students. These students were mostly able to attain 80%-90% of the passing mark. The standard of the examination questions was constantly being reviewed by an examination board comprising representatives from both universities and HKMC.
The passing rate for the LE which took place from September to December 1996 was 7.14% for Part I, 62.8% for Part II and 30% for Part III. Of the candidates participating in the LE, over 90% were from Taiwan or China, and none were graduates from previously recognized overseas institutions.
Students taking part in Part III of LE would be examining patients of common diseases. They would be taking the examination together with other HKU students, and would be judged by external examiners.
Students could be allowed to take the LE for a maximum of five times. A student could apply to have his sixth attempt at LE provided that an acceptable reason was given.

13. Regarding the examination taken by HKU and CUHK medical students and how it differed from the LE, members were given to know that apart from multiple choice questions, students from HKU and CUHK were also required to answer essay questions by subjects in their fourth year. These scores would add up with the grading attained from their clinical examination at the fifth year in assessing their performance. Those who attained the passing mark would be qualified for registration as medical practitioners.

14. In response to members, the Administration was requested to provide more information from the University Grants Committee on the system of examination in HKU and CUHK, the passing rate of these medical students and in what ways were the university examination different from the LE.

Adm

15. Responding to Dr Huang Chen-ya's enquiry about whether the system of LE could be brought closer in line with HKU and CUHK examination, Professor LIEH MAK stated that this would require extra time and resources and further planning. Currently, the university examinations were split into stages according to the subjects while the LE was a composite examination. However, the standard and content of the examination was basically the same. Administrative arrangements were in place to facilitate the return of overseas medical graduates. These included minimizing the time gap between different parts of the examination, holding two examinations annually, exempting test of English (Part II), reducing the period of assessment following the LE, and granting limited registration.

Implementation difficulties

16. Dr LEONG Che-hung pointed out that there would be implementation difficulties in the recognition of overseas institutions. Since the Bill proposed to reinstate the recognition of overseas institutions, any further changes of recognition by GMC would have an effect on the implementation of the Bill. Furthermore, as the Bill proposed that automatic registration provisions be reinstated to those who had enrolled in recognized overseas institutions and who had not had the experience necessary for registration prior to the commencement of MR(A)O 1995, this would lead to further unfairness since those who had completed their studies in recognized institutions before 1 September 1996 would not be able to benefit from the transitional provisions.

17. Representatives of HKMC concurred that there would be implementation difficulties with the passing of the Bill with regards to the problem of recognition of overseas institutions. Graduates from recognized overseas institutions who have attained their medical qualifications prior to the commencement of MR(A)O 1995 but who had not yet been registered in Hong Kong would need to pass the LE, undertake internships before being able to practise in Hong Kong.

Discussion with Hong Kong Medical Association (HKMA)

18. Dr K H LEE iterated HKMA's opposition to the Bill. He stated that HKMA was in support of the present registration system which was considered most fair, being based on a uniform standard of assessment. Commonwealth graduates should be able to complete the registration requirements with no difficulty. The Bill proposed would create unfairness by reinstating preferential treatment to Commonwealth graduates and would give rise to practical difficulties in implementation. The Bill would likely open the floodgate for foreign medical graduates because it was difficult to defend why Commonwealth graduates could be registered whole those of other countries could not. Mrs Selina CHOW failed to agree that the Bill would open the floodgate for foreign medical graduates. She pointed out that the ad hoc committee of HKMA was earlier in support of legislative amendment to MRO but HKMA had later changed its stance.

19. In response, Dr K H LEE confirmed that an ad hoc committee of HKMA was set up to look into the need for legislative amendment. By September 1996, the Council of HKMA had formed the opinion that medical students studying in recognized overseas institutions should not be affected by MR(A)O 1995. Therefore, HKMA was not in support of further legislative amendment to MRO.

Discussion with representatives of students and parents

20. Representatives of students and parents raised the following concerns -

that the negative marking system being applicable to multiple choice questions in the LE but not to essay questions in university examination was unfair;
that the LE system lacked transparency. Students did not have any idea about how they fared in the examination or why they failed; and
that it would be difficult for students without the necessary experience to qualify for limited registration, even if they had been offered employment by recognized medical institutions in Hong Kong.

Limited registration

21. On the subject of limited registration, the representative of Hospital Authority stated that where the Authority had decided to offer employment to a medical practitioner who had not been registered in Hong Kong, it would apply to HKMC for limited registration in respect of the applicant.

22. Mr TSE Man-shing supplemented that under the MRO, limited registration would be initially granted for a period not exceeding one year. Renewal of limited registration on an annual basis would be considered on application .

23. Mrs Selina CHOW pointed out that it would defy logic in that medical doctors could be allowed limited registration to practise for several years in Hong Kong without becoming fully registrable. Upon passing the LE, these medical doctors who had been practising for years, would then undergo internship.

24. In response, Mr TSE Man-shing stated that internships could be shortened, depending on the nature of the individual cases. SALA confirmed that under Section 10A(2) of MRO, the period of assessment could be reduced.

General discussion

The way forward

25. Mrs Selina CHOW opined that as HKMC had declined to defer the enrollment date for LE from 30 April 1997 to mid July 1997, there was thus an urgency for the Bill to resume Second Reading debate before the enrollment date, so that affected students would know if they should apply for enrollment in the LE. As the policy aspects of the Bill had been fully deliberated, she suggested that the Bills Committee needed not be activated. Those who would like to clarify the provisions of the Bill could approach her direct.

26. Dr LEONG Che-hung was concerned about the implications of the Bill and the implementation difficulties which might arise with its passage. He would like the Administration to respond to the concerns raised at the meeting. He supported the activation of the Bills Committee to further study the implications of the Bill.

27. Dr HUANG Chen-ya did not support the activation of the Bills Committee. He requested the Administration to provide the requested information as soon as possible so that members could make an informed decision on the matter.

28. The Principal Assistant Secretary for Health and Welfare thanked the Chairman for giving all parties the opportunity to deliberate the Bill fully at the Panel. The Administration had all along supported the setting up of registration systems for professionals to uphold their standard of practice. The introduction of LE under MR(A)O 1995 was seen as a fair and acceptable means of achieving a uniform assessment and was supported by the Administration. The present Bill proposed by Mrs Selina CHOW sought to reinstate the automatic registration provisions to medical graduates from previously recognized Commonwealth institutions. The Administration respected the view of HKMC that legislative amendment which would reinstate preferential treatment would not be appropriate. The administrative measures proposed by HKMC would help to facilitate the registration of overseas medical graduates and meet their desire to return to Hong Kong to serve the community. The Administration needed to examine the implications of the Bill in detail and seek legal advice where necessary.

29. The Director of Health stressed that there were details of implementation which needed to be looked into. The Administration would need time to analyze the provisions of the Bill and also any possible amendment which members might wish to make. As the Bill now stood, she envisaged that there would be practical difficulties in implementing it.

30. Professor LIEH MAK emphasized that what HKMC was most concerned about was the need to uphold the standard of medical care in Hong Kong, in the interest of the general public.

31. Concluding the discussion, the Chairman said that as members held divergent views, the Panel could not come to a conclusion as to whether the Bill should be supported, or whether the Bills Committee set up for the purpose should be activated. He would make a verbal report on the Panel's deliberation to the House Committee at its meeting on 21 March 1997. It would be up to the House Committee to decide on the way forward. Meanwhile, he urged the Administration and HKMC to provide the information requested as soon as possible, to enable a better understanding of the whole issue.

32. There being no other business, the meeting ended at 11:30 am.

Legislative Council Secretariat

8 April 1997

* other commitments

Last Updated on 19 August 1998