Panel on Health Services (Minutes) 20 Jul 99

Legislative Council

LC Paper No. CB(2) 2679/98-99

Ref : CB2/PL/HS

LegCo Panel on Health Services

Minutes of special meeting
held on Tuesday, 20 July 1999 at 8:30 am
in Conference Room A of the Legislative Council Building Members Present:

Hon Michael HO Mun-ka (Chairman)
Dr Hon LEONG Che-hung, JP (Deputy Chairman)
Hon Cyd HO Sau-lan
Hon CHAN Yuen-han
Hon Mrs Sophie LEUNG LAU Yau-fun, JP
Dr Hon YEUNG Sum
Dr Hon TANG Siu-tong, JP

Members Absent :

Hon HO Sai-chu, SBS, JP
Hon YEUNG Yiu-chung
Hon LAW Chi-kwong, JP

Member Attending :

Hon Emily LAU Wai-hing, JP

Public Officers Attending :

Mr Gregory LEUNG, JP: Acting Secretary for Health and Welfare
Mr Eddie POON: Principal Assistant Secretary for Health and Welfare (Medical) 3
Dr T A SAW: Deputy Director of Health 1
Dr W M KO: Deputy Director, Hospital Authority

Attendance by Invitation :

Consumer Council: Mrs CHAN WONG Shui, BBS, JP; Mr Ron Cameron
Department of Nursing, The Chinese University of Hong Kong: Professor Ann Mackenzie
Department of Nursing Studies, The University of Hong Kong: Dr Agnes Tiwari
Hong Kong Clinical Psychologists Association: Ms May WONG; Mr Helios LAU Ka-cho
Association of Hong Kong Nursing Staff: Mr Michael MAK; Mr YU Kin-yip; Mr LAU Che-wah; Mr LEUNG Yiu
Department of Nursing and Health Science, Hong Kong Polytechnic University: Dr Thomas WONG
School of Business, The University of Hong Kong: Professor Richard Y C WONG

Clerk in Attendance :

Ms Doris CHAN: Chief Assistant Secretary (2) 4

Staff in Attendance :

Ms Joanne MAK: Senior Assistant Secretary (2) 4

I. Meeting with deputations

The Chairman welcomed the deputations to the meeting.

Consumer Council
(LC Paper No. CB(2)2605/98-99(01))

2. Mrs CHAN WONG Shui, Chief Executive of the Consumer Council (the Council), referred to the Council's submission tabled at the meeting and said that she would comment from the perspective of consumers' rights and fair competition of health care. Mrs CHAN outlined the three major concerns of the Council as set out in paragraph 3 of the Chinese version of the submission. With regard to planning information, the Council believed that the proposed Institute for Health Policy and Economics would help to determine the best use of resources. Mrs CHAN emphasized the need to improve the dissemination of information on health care services to consumers and the importance of consumers' choice. She also highlighted key elements of an effective redress mechanism and pointed out that the Council supported the creation of an Ombudsman Office proposed in the Harvard Report to provide assistance and redress to consumers with complaints about health care. As to the Health Security Plan (HSP), Mrs CHAN said that the proposal could address to some extent the anticipated financing difficulties and comply with the principle that Government budget should be kept commensurate with the growth rate of Hong Kong's GDP. As regards the "money follows the patients" concept, the Council was of the view that the Government should consider issues like affordability of patients and consumers' choice before making a decision on the matter.

Professor Ann Mackenzie, Professor of Clinical Nursing and Chairman of the Department of Nursing, The Chinese University of Hong Kong (CUHK)
(LC Paper No. CB(2)2595/98-99(01))

3. Professor Ann Mackenzie pointed out that the Harvard Report had made little comment on the roles of non-medical health care providers such as nurses in health promotion and prevention. She emphasized that nurses greatly influenced the quality and effectiveness of health care and played a major role in the community in promoting patient and family health. Professor Mackenzie gave her views as detailed in the submission on how to expand the role of nurses in the health care system. To illustrate this point, she gave the example of the United Kingdom (UK) where in mobile clinics, adolescence and drug addiction centres and in general practitioners' offices, nurses saw patients without doctors' referral and provided them with advice on health care. In these settings, nurses were seen as expanding the quality of health care service and not replacing doctors in the service. Professor Mackenzie pointed out that expanding the role of nurses to their full potential would contribute to a more cost-effective service and increased value for money. Nurse led intervention could prevent complications by early diagnosis of health problems and save resources by appropriate medical referrals and patient education.

Dr Agnes Tiwari of the Department of Nursing Studies, The University of Hong Kong (HKU)
(LC Paper No. CB(2)2595/98-99(02))

4. Dr Agnes Tiwari said that in response to the Harvard Report, the Department of Nusing Studies of HKU considered that Hong Kong needed a health care system which was restructured and reoriented to provide quality, equitable, affordable, accessible, cost-effective, user-friendly, client-oriented care to Hong Kong residents. She said that this would involve the creation of an integrated, client-oriented health care system. She further made the point that nurses, although being the largest group of health care providers internationally, were underused in the present health care system. Their professional role should be expanded based on the best interests of the clients. Advanced practice nurses, educated at the master and doctoral levels, were key primary care providers and a critical component of health care reform. These highly qualified nurses should be utilized to the fullest extent possible to effect positive changes in health care.

Hong Kong Clinical Psychologists Association (HKCPA)
(LC Paper No. CB(2)2595/98-99(04))

5. Ms May WONG of HKCPA gave a presentation to introduce the HKCPA and explain how clinical psychology could contribute to health care. She pointed out that the HKCPA agreed with the Harvard Report in that the health care system in Hong Kong was highly compartmentalized and it lacked a coherent overall policy for financing or organizing health care. The HKCPA urged the Government to devise comprehensive health policies and not just to focus on reforming the financing and structural systems. As psychological factors had proved to be significant in primary prevention of some of the main causes of death such as coronary heart disease and cancer, the HKCPA advocated incorporating psychological services in primary care settings. Ms WONG pointed out that health care was not just medical care and that a team approach in recognition of the equal contributions made by various non-medical professionals to health care should be emphasized.

6. Mr LAU Ka-cho of the HKCPA said that it was necessary to protect the public from substandard services provided by those who were not properly or adequately trained and yet had claimed themselves to be psychologists. He called on the Government to put in place a statutory registration system for psychologists.

Association of Hong Kong Nursing Staff
(LC Paper No. CB(2)2595/98-99(04))

7. Mr Michael MAK of the Association said that the Harvard Report had concentrated its comments on medical care. It had failed to provide a comprehensive review and neglected the roles played by other health care professionals such as nurses, occupational therapists and pharmacists. With reference to the Association's submission, Mr MAK pointed out that improvements required for the health care system should include tightening the monitoring system of private and public hospitals, strengthening both primary health care services and the coordination of the services. He urged the Government to consider enlarging the scope of responsibilities of the Department of Health (DH) and to provide it with additional resources to coordinate the provision of various kinds of primary care services and promoting health knowledge of the public. He pointed out that the promotion of primary health care was the most cost-effective way to control health service cost and improve the health of the general public. In particular, since nurses were of "good quality and low in costs", they should play a major role in promoting primary health care.

8. On health care financing, Mr MAK said that the Association was opposed to the options of maintaining the status quo and capping the Government budget on health because these two options would not help to resolve the problems of the health care system. As regards the the options of raising user fees, the HSP and the proposed savings scheme for long term care (MEDISAGE), the Association considered that it was necessary for the Government to provide more details to facilitate deliberations on these options.

Dr Thomas WONG of the Department of Nursing and Health Science of Hong Kong Polytechnic University (HKPU)
(LC Paper No. CB(2)2605/98-99(02))

9. Dr Thomas WONG advocated that the financial benefits of nurses and other health care professionals in the health care system should be valued and confirmed. The Hospital Authority (HA) should adopt a policy which could better utilize the contribution that could be made by nurses and other health care professionals in providing health care services. He believed that such a policy would achieve greater cost-effectiveness and raise the overall standard of public health services.

10. Dr WONG considered that the Government should continue to provide basic health services. Additionally, an insurance or savings system might have to be established to meet expenditures for more sophisticated health care services. He emphasized that no one should be deprived of the right to obtain basic medical care because of inability to pay for it. He also supported establishing a central databank to collect health related data.

Professor Richard Y C WONG, Director of the School of Business, The University of Hong Kong

11. Professor Richard WONG said that as he had pointed out on two previous public occasions, he had reservation about several points in the Harvard Report. However, he considered it important that the Report had raised for discussion the weaknesses in the existing health care system and the problems which would be encountered in health care financing. Professor WONG took the view that the public health expenditure should be considered as a social investment to raise the quality of the population as the state of physical and mental health was very important and a higher life expectancy had a positive effect on the society.

12. As to health care systems, Professor WONG pointed out that there were three major health care financing models:

An insurance system with or without government subsidies -

This would allow market competition and could link up various levels of care. It could avoid compartmentalization and could fully reflect patients' needs. As equity and cost effectiveness could be achieved, economists generally supported this system. As an economist, he supported the system with some reservation. Due to information asymmetry in any health care system no matter how well it was designed, it ran the risks of moral hazard and costs running out of control as in the case in the United States (US).
Government funding based on tax revenue -

This system, which was the main feature of the status quo, could achieve equity as everyone could get the same service. However, patients would have no choice, there would be no guarantee of the quality of care and compartmentalization would continue to exist; and
Private health care on a fee-charging basis with private medical insurance -

This was also an efficient system but those lacking means might not be able to afford such service.

Professor WONG pointed out that the different systems met the needs of different patients and he was in favour of the co-existence of all the three systems which could supplement each other.

13. Professor WONG considered that the problem with the current financing system of Hong Kong's health care was that it had allowed the public-funded HA to become too large. There was a need for it to be downsized and for its role to be restricted to allow room for development of other providers and models.

14. Professor WONG took the view that the financing reform was inseparable from health care reform as the two were interrelated. In addition to targetting health care financing, the Harvard Report also raised the need for health care reform. He therefore considered that the consultancy fee was well worth the money. He supported putting in place a subsidized voluntary insurance system for Hong Kong's health care instead of a compulsory system as proposed by the Harvard team. He pointed out that health care reform required much data and information, and in the absence of such information and data now, the Government should adopt a gradual approach in bringing about any new changes or establishing a new financing model and it must not abolish the existing system overnight. Professor WONG concluded his comments by expressing support for the establishment of an Institute for Health Policy and Economics.

Questions raised by Members

15. Referring to the projection made by the Harvard team that by the year 2016, public health care expenditures might take up 20% to 23% of the total Government budget, Dr LEONG Che-hung asked for Professor Richard WONG's views on the projection. In reply, Professor WONG said that he was unable to give an answer now due to incomplete data that was available for the time being. As it was uncertain whether the projection would come true or not, Professor WONG considered that it was time to start exploring the problems as pointed out and seeking ways to resolve them.

16. In response to Dr LEONG Che-hung's further question, Professor WONG said that he supported reducing the services provided by the public health sector. However, he clarified that this did not mean that the Government should thus reduce its budget for public health care. Instead, what he advocated was that the subsidies should go direct to the patients instead of to the providers.

17. Professor WONG agreed with Dr LEONG that the problem of information asymmetry existed in every profession. He considered that the removal of some restrictions imposed on the health care system could help improving the situation to an extent. For example, he noted that the Medical Council of Hong Kong (HKMC) disallowed physicians to advertise their services, which he considered was adding further to the problem of information asymmetry in the medical profession.

18. In response to Miss CHAN Yuen-han's question about his preferred health care financing model for Hong Kong, Professor Richard WONG said that he was in favour of the dual system of public health services and a health insurance system. Competition of these two mechanisms would lead to improvement of efficiency in the public health sector. Moreover, the Government could further decide to invest more in which of the two mechanisms by taking into account which one achieved greater cost-effectiveness. Professor WONG also suggested that the Government should reduce the magnitude of the health services provided by the HA. As to why it should be a "subsidized" insurance scheme, Professor WONG explained that government subsidies were required to ensure that vulnerable groups such as the elderly would also be covered under the insurance scheme. He pointed out that even in the US, there was a strong element of government subsidies in the health insurance scheme although he was not suggesting that Hong Kong should model on the health care funding system of the US.

19. Miss Cyd HO Sau-lan sought Professor WONG's views as how to ensure that there would be insurance companies willing to underwrite the elderly people especially those suffering from chronic diseases under the health insurance scheme he suggested. She also requested Professor WONG to elaborate further his views on how the government subsidies would go direct to the patients instead of the providers. She asked that, supposedly the Government had finally decided to adopt a compulsory health insurance system which would result in a large inflow of cash to the market, what impact this would have on Hong Kong's economy. Finally, Miss HO referred to the fact that some 80% of the health service costs were actually made up of staff remuneration and asked Professor WONG whether there was any solution to the problem of high staff costs.

20. In reply, Professor Richard WONG explained in greater detail the subsidized voluntary insurance system and pointed out that the Government in the first place should decide how much it was going to spend on health services. Then it would have to decide how to divide it up between the HA and subsidies for health insurance. Under this insurance system, patients were also required to pay for part of the costs but they were entitled to have a free choice of providers/hospitals. However, patients who opted for the subsidized health insurance scheme would be excluded from the services of the HA. Unlike the Harvard Report which suggested that such insurance service should be provided only by hospitals and organized medical and health professional groups, Professor WONG took the view that insurance companies should also be allowed to provide the insurance service and that these companies being subsidized by the Government would be required to underwrite the elderly people and those suffering from chronic or even terminal diseases. Professor WONG further made the point that this insurance scheme would not be of a smaller scale than the Mandatory Provident Fund and he called on the Government to be very careful in the planning of it.

21. Professor WONG pointed out that the financing model which he advocated would incur additional administrative cost to the Government. However, the co-existence of the subsidized voluntary insurance system and public health sector would bring about competition between the two which would lead to improvement of efficiency and cost savings. As regards the high remuneration of staff, Professor WONG took the view that this factor existed in other sectors as well such as in the tertiary education sector. He noted that there was now a general trend of downward adjustment of staff remuneration and he believed that if more competition could be introduced, the HA would be forced to take more effective measures to achieve cost savings.

22. In reply to the penultimate question raised by Miss Cyd HO Sau-lan, Professor WONG said that the large inflow of cash into the market as a result of the implementation of a compulsory health insurance system might foster the development of the financial market of Hong Kong. Since the amount of the cash inflow would be quite predictable and stable each year, it would not constitute a 'hot money' situation. However, he pointed out that the impact brought about by a health insurance scheme to the financial market should not be a consideration factor in designing the health care financing model for Hong Kong.

23. Dr YEUNG Sum asked Professor WONG whether he considered that the status quo for the health care financing system could be maintained by controlling costs by administrative means. In response, Professor WONG said that instead of using administrative means, he was more in favour of introducing competition to a system which he considered was the most effective way to encourage cost control in a system. Commenting on the HSP, Professor WONG was worried that with abolition of the HA, the HSP would become the sole mechanism without having to compete with other systems and he doubted whether it would really operate by market principles. He was worried that in the end, the HSP would become in effect a means to increase taxation without changing anything. Since cost control depended essentially on the premium set for the HSP, he was also concerned about the membership of the Board which would be responsible for the management of the HSP and setting the amount of the premium.

24. Miss Emily LAU Wai-hing was interested to know whether nurses could replace doctors in certain health service settings. She invited the representatives from the nursing profession to give their views on the appropriate health care financing model or to comment on the one advocated by Professor Richard WONG. In reply, Professor Ann Mackenzie clarified that she was not advocating that nurses should replace doctors. She said that nurses should work alongside doctors to expand the quality of health care and make it more comprehensive. For example, nurses could perform more tasks such as providing health education to patients. In this way, doctors could concentrate more time on other medical tasks. She agreed that there were situations where nurses might see patients first and decide whether it was necessary to refer the patients to see a doctor or a social worker. In the UK or US, there were clinics where nurses saw patients first without a referral. Miss Emily LAU Wai-hing commented that this mode of operation was very innovative and cost-effective and she suggested the DH to explore the option.

25. Mr Michael MAK of the Association of Hong Kong Nursing Staff pointed out that the training of nurses had enabled them to provide a variety of services such as assessing the conditions of patients and providing different kinds of care services. Given the large range of services that nurses could perform, Mr MAK said that nurses could certainly help to achieve greater cost-effectiveness for health care. He took the view that every group of health care professionals had their own expertise and they should not be required to see patients by doctors' referral.

26. In response to Dr TANG Siu-tong's query as to whether nurses could do cervical smear for patients, Professor Mackenzie said that it was perfectly feasible for nurses to do the examination of cervix provided that they had received the proper training. She emphasized that the primary health care was multi-disciplinary and the Government should formulate policies to help to develop the potential of each kind of the primary health care professionals.

27. Dr Thomas WONG of the Department of Nursing and Health Science of HKPU added that nurses were now already responsible for the triage system to assess the conditions of patients in the accident and emergency departments in public hospitals to decide the priority order for attendance by doctors. He pointed out that 20% of patients attending hospitals were actually related to chronic diseases. These patients did not need to be hospitalized and checked by doctors everyday and they could be taken care of by nurses only.

28. Responding to the second question of Miss Emily LAU Wai-hing, Mrs CHAN WONG Shui of the Consumer Council considered that the greatest merit of the insurance scheme proposed by Professor Richard WONG was that it was voluntary and it allowed competition. However, she pointed out that to implement the insurance system, it was necessary for the Government to provide more information to patients so that they could make appropriate decisions on the choice of providers. She was also concerned whether this financing model would encourage patients to obtain services from the private sector which in turn would receive more resources. On the other hand, the public health sector receiving less resources would decline in its standard of service. Dr Thomas WONG supported that it should be a voluntary health insurance rather than a compulsory one so that patients could choose to join it or not. At the same time, he advocated that a private insurance scheme should co-exist with the subsidized one for the benefit of competition.

29. Dr TANG Siu-tong referred to Dr Thomas WONG's suggestion that the Government should be responsible for providing basic health care services and sought Dr WONG's views on how to define "basic health care services". In reply, Dr WONG agreed that it was very difficult to define the scope. As there should be public consensus on the matter, he suggested that it should be worked out by a committee comprising members of the public. He pointed out that there must be an upper ceiling for health care expenditure in order to define the scope of services.

30. Referring to a point made in Dr Thomas WONG's submission, Mrs Sophie LEUNG asked if there were any concrete suggestions as to how to achieve "a paradigm shift from medical dominance to a multi-disciplinary health care environment". In response, Dr Thomas WONG said that, apart from the support of the HA, the nursing profession itself would also need to endeavour to achieve this goal. Professor Mackenzie agreed that the nursing profession should be addressing this issue. She was pleased to note that efforts were being made to increase the number of graduates of nursing. She agreed that nurses at the bachelor level should be better trained in many aspects than nurses at the diploma level. Mrs Sophie LEUNG took the view that the nursing profession itself had a lot more to do instead of waiting for the Government or the HA to do something to enhance their roles as primary health care providers. She appreciated the recent move of the HA which had closed down the hospital-based nurses training schools to change nurses training from hospital-based to university-based. She considered that nurses training should put more emphasis on the development of students' leadership quality.

31. The Chairman asked Mrs CHAN WONG Shui whether the Consumer Council would consider proposing to the Government to make it a compulsory requirement for doctors to display a scale of fees at their clinics. In response, Mrs CHAN said that they had made this point to the HKMC. Although the HKMC agreed that patients had the right of knowing the scale of fees, it had met resistance from some doctors and some were only willing to do so upon request. Nevertheless, the HKMC had agreed to further pursue with the matter. Mrs CHAN said that given the wide discussion on the subject now, she believed that more doctors would be willing to comply.

32. In response to Miss CHAN Yuen-han's question, Mrs CHAN WONG Shui said that as set out in the submission of the Consumer Council, there were pros and cons for the option of capping the Government budget on health services. She said that at the moment the Consumer Council had no preference for any of the financing options proposed in the Harvard Report.

33. Miss Emily LAU Wai-hing noted that the Consumer Council had been liaising with the medical profession to seek improvement of the redress mechanism. She enquired about the progress and whether it was true that the Consumer Council would very soon help setting up an independent Ombudsman Office. In response, Mrs CHAN WONG Shui said that for three years a working group had been formed comprising representatives from the Consumer Council and the Hong Kong Medical Association to look at the mechanisms for handling medical complaint cases. She agreed that the current system involving various complaint mechanisms was far from satisfactory and she supported the establishment of an Ombudsman Office. She further suggested that if the Ombudsman Office was formed, it should be also tasked to investigate into complaints made against the X-ray centres, occupational therapist clinics and so on.

34. The meeting ended at 10:50 am.

Legislative Council Secretariat
16 August 1999