Panel on Health Services (Minutes) 28 Jun 99

Legislative Council

LC Paper No. CB(2)2656/98-99
(These minutes have been
seen by the Administration)

Ref : CB2/PL/HS

LegCo Panel on Health Services

Minutes of special meeting
held on Monday, 28 June 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 HO Sai-chu, JP
Hon CHAN Yuen-han
Hon Mrs Sophie LEUNG LAU Yau-fun, JP
Hon YEUNG Yiu-chung
Hon LAW Chi-kwong, JP
Dr Hon TANG Siu-tong, JP

Members Absent :

Hon Cyd HO Sau-lan
Dr Hon YEUNG Sum

Member Attending :

Hon Emily LAU Wai-hing, JP

Public Officers Attending :

Ms Jennifer CHAN: Deputy Secretary for Health and Welfare 1 (Acting)
Mr Eddie POON: Principal Assistant Secretary for Health and Welfare (Medical) 3
Dr T A SAW: Deputy Director of Health 1
Dr S Y LEE: Principal Medical and Health Officer 4; Department of Health
Dr W M KO: Deputy Director, Hospital Authority

Attendance by Invitation :

The Medical Council of Hong Kong: Professor Felice LIEH MAK
Hong Kong Academy of Medicine: Dr David FANG
The Hong Kong College of Family Physicians: Dr Donald LI; Dr WONG Wai-hung; Dr IP Kit-kuen
Faculty of Medicine of the Chinese University of Hong Kong: Professor Joseph C K LEE
The Pharmaceutical Society of Hong Kong: Mr Benjamin KWONG
Faculty of Health and Social Studies of the Hong Kong: Polytechnic University; Professor George WOO
Hong Kong Society of Professional Optometrists: Mr Dominic KIM
Estate Doctors Association: Dr LAM Ying-ming

Clerk in Attendance :

Ms Doris CHAN: Chief Assistant Secretary (2) 4

Staff in Attendance :

Ms Joanne MAK: Senior Assistant Secretary (2) 4

I. Hong Kong's Health Care System and Direction of Future Reform

The Chairman welcomed the deputations to the meeting.

2. The Chairman informed members that in addition to the special meeting on 12 July 1999 at 8:30 am, two additional meetings had been scheduled for 20 and 21 July 1999 both at 8:30 am to discuss the Harvard Report. In view of the schedule of meetings which would run up to 21 July 1999 the earliest, the Chairman requested the Administration to consider extending the period of the consultation in respect of the Report. Deputy Secretary for Health and Welfare 1 (Acting) (DS(HW)(Ag)) agreed to consider the suggestion and revert back to the Panel within the following week.

(Post-meeting note : the Administration announced on 5 July 1999 that the consultation period would be extended to 15 August 1999.)

Meeting with deputations

The Medical Council of Hong Kong (HKMC)

3. At the Chairman's invitation, Professor Felice LIEH MAK, chairperson of HKMC, said that the HKMC was concerned about the ways to ensure the provision of high quality medical care in Hong Kong. She informed members that the HKMC had decided that all general practitioners would be required to undergo continuous medical education. In the meantime, it was collecting views on the necessary measures conducive to a high standard of medical care.

4. Professor LIEH MAK also informed members that the HKMC was considering to increase the number of its lay members in a bid to enhance its transparency and accountability.

Hong Kong Academy of Medicine (HKAM)

5. Dr David FANG, president of the HKAM, said that the problem of variable quality of health care had long existed in Hong Kong. The HKAM therefore sought to enhance the professional standards of medical doctors by fostering the development of continuous medical education and organizing medical specialist training. It supported the HKMC's suggestion of requiring all practising medical practitioners to undergo continuous medical education. In addition, the HKAM would introduce a quality assurance system for medical service.

6. As regards the problem of a high degree of compartmentalization of Hong Kong's health care system as pointed out in the Harvard Report, Dr FANG said that the HKAM was of the view that strengthening primary care and developing family medicine were effective ways to resolve the problem.

7. On health care financing, Dr FANG cautioned members to deliberate very carefully on the matter and pointed out that in Taiwan the government had assumed the responsibility of providing all kinds of health care and that such a system had already proved to be financially unsustainable. He supported the concept of "patient records following the patients" rather than the "money follows the patients" concept.

8. Dr FANG said that since resources were limited, public health services should be targetted to benefit only those who could not afford to pay. On the other hand, the Government should continue financing health promotion and disease prevention. The HKAM was also in support of maintaining the dual system of public and private health care systems so that patients could have a free choice of providers.

The Hong Kong College of Family Physicians (HKCFP)
(LC Paper No. CB(2)2266/98-99(06))

9. With reference to their submission, Dr Donald LI, Dr WONG Wai-hung and Dr IP Kit-kuen briefed members on the views held by the HKCFP regarding -

the importance of developing primary care / family medicine in Hong Kong and how to uphold the standards;
the system proposed by the HKCFP to assess the standards of service providers in the sector; and
the training of family doctors.

Professor Joseph C K LEE, Dean of the Faculty of Medicine of the Chinese University of Hong Kong
(LC Paper No. CB(2) 2414/98-99(02))

10. Professor Joseph LEE presented his views on health care structure, financing and quality as set out in his submission.

The Pharmaceutical Society of Hong Kong (HKPS)
(LC Paper No. CB(2) 2414/98-99(03))

11. Mr Benjamin KWONG, chairman of HKPS, pointed out that the long-term target of the HKPS was to have complete separation of the dispensing and the prescribing systems, which would better ensure the quality of drug prescription. With reference to the HKPS' submission, Mr KWONG explained how pharmacists could participate more widely and actively in primary health care. He said that the HKPS advocated that Hong Kong should follow the example of Denmark which had started in 1989 to increase the number of Pharmacy Only medicines so that patients could seek help readily from the community pharmacists. The HKPS was of the view that pharmacists could serve as an interface between the private and public health sectors. In addition, pharmacists could help in the education of the public on the choice of and the appropriate use of drugs and also in health promotion. To enable pharmacists to have greater control in and more professional input to pharmacy services, the HKPS considered that it would be desirable if pharmacists were required to be owners and co-owners of pharmacies. Mr KWONG said that the HKPS supported the development of family medicine and training of community pharmacists, which, however, were not mentioned in the Harvard Report.

Professor George WOO, Dean of Faculty of Health and Social Studies of the Hong Kong Polytechnic University
(LC Paper No. CB(2)2395/98-99(01))

12. With reference to his submission paper, Professor George WOO expressed his opinions on the necessary measures to be taken for improvement in the delivery of health care services in Hong Kong. He emphasized that there was a need to engage optometrists in providing primary eye care services under the Hospital Authority (HA) and the Department of Health (DH) in order to provide efficient and cost-effective eye service to patients. He pointed out that an optometrist should be the first one to see the patients and provide primary eye care services to them when they suffered from eye diseases.

Hong Kong Society of Professional Optometrists (the Society)
(LC Paper No. CB(2)2395/98-99(02))

13. Mr Dominic KIM, chairman of the Society, pointed out that the crux of the problem of compartmentalization of the health care system lay with the fact that the Government had neglected the importance of non-medical health care professionals. He urged the government to involve optometrists as primary health care practitioners in order to improve the cost-effectiveness and efficiency of eye service in Hong Kong.

14. Mr KIM said that the Society considered that the Government should bear full responsibility for the problem of strong medical dominance in Hong Kong's health care and he questioned why the chairman of the Optometrists Board had to be a medical doctor. He said that the Society agreed with the comment in Harvard Report that Hong Kong lacked a coherent overall policy for financing or organizing health care. The Society urged the Administration to re-consider the roles played by health care professionals including optometrists, nurses, physiotherapists and pharmacists and identify the areas in which these professionals could contribute to the delivery of primary health care in Hong Kong. To raise their professional status, the Society supported that the Supplementary Medical Professions Ordinance should be replaced with an ordinance for each of the non-medical health care professions.

Estate Doctors Association (EDA)
(LC Paper No. CB(2)2414/98-99(04))

15. Dr LAM Ying-ming briefed members on the views held by the EDA as set out in its submission. The EDA supported privatization of out-patient clinics if this was proved to be more cost-effective and that hospital-based services should be provided mainly by the public sector.

Questions raised by Members

16. In response to Dr LEONG Che-hung's request for inviting more representatives from non-medical health care professions to attend the meetings for discussion of the Harvard Report, the Chairman said that the arrangements had been made.

17. Dr LEONG Che-hung expressed support for the appointment of more lay members to the HKMC. However, he considered that it was important to always maintain at least half of its members to be medical doctors in order to achieve self-regulation for the profession.

18. Dr LEONG Che-hung agreed that it was desirable to have pharmacists to be owners of pharmacies so as to avoid "monopoly" of the trade by businessman and to let pharmacists have more control of the professional standard of the pharmacy services. He considered that the Society should make more suggestions on how to achieve the purpose. The Chairman questioned whether there were adequate pharmacists in Hong Kong to support the separation of prescribing and dispensing the systems as advocated by the HKPS. In response, Mr Benjamin KWONG pointed out that before a total separation of prescribing and dispensing systems was in place, it was difficult to encourage ownership of pharmacies by pharmacists. As regards the question of manpower, Mr KWONG was of the view that it would not be a problem since the supply could be adjusted if the Government was willing to commit the necessary resources. He pointed out that it would certainly help to reduce the public expenditure on health care if pharmacists played the role as a first contact primary health care by prescribing for mild illnesses such as common colds.

19. Dr LEONG Che-hung referred to the submission made by the Society to the Working Group on Primary Care in 1989 (Appendix 1 to LC Paper No. CB(2)2395/98-99(02)) and queried why their views had never been brought to the attention of LegCo Members for follow-up. In response, Mr Dominic KIM said that the sector had been engaged in the pursuit of legislation for the profession which was only put in place in April 1996. At the Chairman's request, Mr KIM agreed to provide a more detailed paper to the Administration and this Panel to explain how optometry could be an independent primary health care profession and what the Society had done in the past 10 years in reflecting their views to the Administration.

20. In response to Dr LEONG Che-hung's concerns, the Chairman requested the HA to provide an information paper to explain its policy on optometry such as the role of hospital optometrists.	HA

21. Miss Emily LAU Wai-hing said that she was glad to hear that arrangements had been made to invite non-medical professionals to participate in the discussion on the Harvard Report at the next few meetings. She considered that this was important to avoid giving the public an impression that even LegCo Members were in support of the Government's long standing policy of siding with the medical profession, which had led to medical dominance in the health care system and given the profession a superior status in Hong Kong as seen from the fact that doctors were often appointed to the ExCo and LegCo. She appealed to the medical profession to be open and give their views on how to establish a more balanced health care system in place of the medical monopoly so that the importance of non-medical professions could be recognized.

22. Dr Donald LI considered that it was essential to establish a good physician/patient relationship and to rectify the improper attitude of patients towards doctors. He considered that if a patient from the very beginning believed in medical monopoly and did not trust the doctors, the doctors could do nothing to help the patient without the patient's trust. He took the view that it should begin with primary education to teach children the concept of a good physician/patient relationship and the importance of family medicine. Therefore, the training of family medicine emphasized the establishment of the physician/patient relationship. In addition, family doctors advised patients on matters related to personal hygienic and self-care which were very important to disease prevention. He was concerned that community pharmacists inevitably would emphasize medication and lead to reliance on it. Dr IP Kit-kuen took the view that the status of medical doctors was attributable to the legislation governing the profession as passed by the LegCo.

23. The Chairman said that the meeting should not be taken as the forum to argue on the issue of medical monopoly. He observed that it would require a lot of time to trace back the history to see under what circumstances the relevant legislation had been passed. Miss Emily LAU Wai-hing agreed with the Chairman and pointed out that the relevant legislation had been passed a long time ago before she was elected to be a LegCo Member. Referring to Dr Donald LI's comments, Miss Emily LAU Wai-hing considered that the attitude of the public towards doctors could not be changed without first breaking the medical monopoly. She took the view that the primary health care services should encompass all health care professionals so that the patients would know that they could also turn to non-medical health care professionals. She considered that doctors had been looked upon as "god" and even the Harvard Report also highlighted the fact that the medical profession had a very superior status in Hong Kong. She considered that the Administration should bear full responsibility for this problem.

24. Speaking in his personal capacity, Dr KO Wing-man explained the efforts that the HA had made to avoid giving the impression that doctors were superior to allied health professionals in the HA. He considered that on the one hand, doctors should not defend their turf and on the other hand, no one should accuse the others of creating a monopoly. He considered that one should adopt an open attitude in examining this issue. He opined that the status of medical doctors also had to do with the history of the development of health care services.

25. Miss Emily LAU Wai-hing considered that the problem of medical dominance should be addressed as this was the crux of the problems pertaining to Hong Kong's health care. She recalled that when the registration of chiropractors was discussed at the LegCo a few years ago, the chiropractors were not allowed by the medical profession to call themselves "doctors". She considered that the incident was an example of medical dominance in Hong Kong.

26. Dr LEONG Che-hung disagreed that the representation of medical doctors in the ExCo and LegCo should be seen as a kind of "dominance" of the profession in Hong Kong. He pointed out that barristers/solicitors were also represented in the ExCo or LegCo. He considered that the allegation of medical dominance made by Miss Emily LAU Wai-hing would make the discussion become "unhealthy" and took the view that the status enjoyed by doctors had been hard earned by the profession. Mrs Sophie LEUNG agreed with Dr LEONG and further pointed out that the public did not expect members to spend time on arguing instead of considering the way forward for Hong Kong's health care. She agreed with Dr Donald LI that patients should put their trust in their family doctors but at the same time doctors should not be looked upon as "god ". In response to the advocation of community pharmacists, Mrs LEUNG sought Mr Benjamin KWONG's views as to the comparative advantages of community pharmacists over the HA in attracting patients to consult them. In response, Mr Benjamin KWONG believed that if patients could seek help readily from the community pharmacists, fewer of them would go to HA as deterred by its long waiting time involved. In fact, community pharmacists could provide referral service to patients as and when necessary. He pointed out that community pharmacists had been quite popular in overseas countries where the patients might not be buying drugs when they see a community pharmacist as the latter's functions were not confined to dispensing. He also took the view that the need for patients' trust in doctors also applied to other health care professionals.

27. Professor Felice LIEH MAK said she did not think that there should be any worry about monopolizing the health care because the nature of illnesses had changed over the years giving rise to the need for other specialties to come in. She considered that instead of arguing about medical monopoly, the health care sector should look at the quality of education and seek ways to maintain/regulate the standard of health care professionals.

28. Dr David FANG agreed that the Harvard Report had not touched on the roles of non-medical health care professionals such as nurses, dentists and so on. He considered there should be quality assurance for them as well. He took the view that the status of doctors had been earned by doctors themselves. However, he agreed that there should be improvement in communication between doctors and patients. He considered that doctors should only be viewed as leader of the health care service and not as "monopolizing" the service.

29. Dr TANG Siu-tong shared the view of Dr David FANG and considered that patients' trust in doctors should be emphasized. He was of the view that doctors were playing the role of a "co-ordinator" of health care instead of monopolizing the services. However, the Chairman commented that other health care professionals should also be able to play the same coordinating role and be allowed to refer patients to see specialties in different fields of health care.

30. Referring to the EDA's comments in support of privatization of out-patient clinics and that hospital-based services should be provided mainly by the public sector whereas primary and secondary health care services should be provided mainly by the private sector, Miss Emily LAU Wai-hing enquired about the justifications behind. In response, Dr LAM Ying-ming of the EDA suggested that as the chairman of the EDA might attend the next meeting, he could explain to members then the justifications for these proposals. However, as there would be quite a number of deputations attending the next meeting, the Chairman requested the EDA to provide supplementary information to the Panel in writing.

31. Dr LEONG Che-hung referred to the submission made by the Hong Kong Dental Association tabled at the meeting (LC Paper No. CB(2)2414/98-99(01)) and enquired why the Harvard Report did not address dental health issues. He asked whether the Administration would address the issues in its final paper. DS(HW)(Ag) assured members that the Administration recognized the importance of non-medical health care professionals in the health care system. She explained that as the Harvard Report had concentrated on the delivery system of health care and its financing, it did not address issues like dental care. However, she informed members that the Health and Welfare Bureau (HWB) was actually conducting a review with DH to seek improvements for primary health care. Principal Assistant Secretary for Health and Welfare (Medical)3 PAS(HW)(M) added that during the review, the HKAM and many other health care professionals' views had been sought on how to improve the primary health care system from the perspective of each of the professions. He pointed out that based on the submissions received so far, there appeared to be consensus on topics like transparency and accountability of the complaints channel, quality assurance, continuous medical education and the suggestion of "patient records to follow the patients" mechanism.

32. PAS(HW)(M) informed members that comments on health care financing were quite diverse and the Administration would need more time to deliberate on the matter. He added that a change in the health care financing arrangement would affect not only patients, but would also alter the behaviour of health care providers. Given the complexity of the subject and its profound impact on the health care system as a whole, the issue of financing would have to be thoroughly studied before a recommendation could be made. In response to Dr LEONG's query of the lack of coverage on dental health issues in the Harvard Report, PAS(HW)(M) explained that the Harvard Team had not been required in their terms of reference to look at every single health care profession in Hong Kong to assess whether or not they had been given the appropriate recognition in the health care system. However, he emphasized that their importance and contributions made to the health care system had not been overlooked and this was reflected in the Special Report No. 1 which had set out the large amount of resources devoted to the services provided by non-medical health care professionals.

33. Dr LEONG Che-hung expressed disappointment with the Administration as it had failed to understand what the public's concerns were about. He pointed out that the concern of the Hong Kong Dental Association was not on whether or not the Harvard Report had mentioned about individual health care service providers such as dentists. Rather, the Association was concerned about whether or not dental and oral care, being an integral part of heath care, would be looked at in the health care review and, if so, the Administration's dental policy. The Chairman agreed that the health care review was concerned about the way forward whereas the Special Report No. 1 quoted only reflected the current position. He also suggested that the Administration should consider setting priorities for the review.

34. DS(HW)(Ag) confirmed that the Administration would issue a paper which would set out the direction that the Administration would pursue in respect of the development of Hong Kong's health care. However, the scope of the paper had yet to be decided. Deputy Director of Health 1 (DD(H)) added that the DH in collaboration with the HWB and the HKCFP were trying to work out the blue print on the way forward for primary medical care in both private and public sectors. It was intended to address various shortcomings such as quality assurance, breaking the barriers between the public and private sectors and comprehensiveness of care.

35. Dr LEONG Che-hung was still dissatisfied with the Administration's reply as it had seen the health care review as one restricted to primary health care only. He reiterated that it was vital for the Administration to formulate its dental policy without which it was hard to say whether there would be any development of the service. Miss Emily LAU Wai-hing also urged the Administration to cover all health care professions in the Review although for unknown reasons the Harvard Team had not been requested to do so. Mrs Sophie LEUNG appealed to the health care sector to give more views to the Administration regarding the reform. She requested the Administration to provide information on the costs incurred in training up a medical doctor, a pharmacist and an optometrist and compare the costs with that in other developed countries.

Adm

36. Professor George WOO agreed that quality assurance was of utmost importance for each health care profession. He found that DD(H) with a slip of tongue still mentioned primary "medical" care whereas the whole discussion in the morning had been about "health care". He reiterated the need to engage optometrists in providing primary eye care services in the eye hospitals. He said that an optometrist should be the first one to see the patient and provide primary eye care services to the patient when he/she suffered from eye diseases. He also read out from a newspaper article that "the bodies which advised the Administration on health matters, such as the HKMC, the Medical Development Advisory Committee and the DH and the former Hospital Services Department, were largely dominated by doctors". Professor WOO considered that these had explained the lack of development of the optometry profession in the past 10 years.

37. In addition, Professor George WOO pointed out more resources seemed to have been allocated to medical development as evidenced in the fact that the HKAM received a large amount of subsidy ($175 million) from the Jockey Club and free land was given by the government for its construction. In contrast, the optometry profession had never received such provisions.

38. In respect of resources allocation, Dr Donald LI invited members to note that the Hong Kong College of General Practitioners was run on a voluntary basis which had never received any subsidies. He also clarified that the HKCFP was not proposing that effective primary health care could only be delivered by practitioners who had reached specialty levels. It had neither suggested that all primary medical practitioners in Hong Kong must have obtained a fellowship from or reached the specialty levels recognized by the HKCFP. Dr LEONG Che-hung took the view that in commenting the allocation of resources to the development of medical care, one should take into consideration the great efforts made by the profession in building its status.

39. On concluding, the Chairman said that it would greatly facilitate the deliberations of the Panel if it could listen to more views of the deputations. He suggested that when the deputations were ready to provide submissions to the Administration explaining in greater detail their views, he would appreciate it if the deputations could provide to the Panel for reference a copy as well.	deputations

40. The meeting ended at 10:55 am.

Legislative Council Secretariat
30 July 1999