by Calvin Lam
HarbourTimes.com|Today, 11:18
The simple complaint that there not enough doctors in Hong Kong masks a complex array of factors that lead to dissatisfaction with waiting times for non-critical procedures. Our medical establishment answers the question ‘are there enough doctors in the house’?
This article was originally posted on February 19, 2014.
Imagine you are awaiting treatment when your life is threatened. Imagine having to wait years to rid yourself of a painful, non-critical disease when the treatment is known and widespread. It sounds unsettling but these situations are common in Hong Kong and are believed to be caused by a shortage of medical professionals – specifically, doctors.
In a reply to Harbour Times, the Hospital Authority (HA) admits to a shortfall of about 310 doctors for the 2013-14 year, in the public hospitals. The figure was 110 in 2011. According to the HA, the shortage is real and getting worse every year.
Doctors, however, think otherwise.
Counting doctors
Registered doctors numbered 13,203 at the end of 2013, meaning there are around 1.8 doctors per thousand population. Graph 1 shows that the ratio falls short compared to other developed countries in the world. The Organisation for Economic Co-operation and Development (OECD) average is 3.2. Statistics tell only one side of the story. Dr. Leung Ka-lau (FC- Medical) speculates the figure for other countries includes research-oriented medical professionals and thereby overstates the actual number of doctors serving the patients in other countries. The Vice President of the Hong Kong Medical Association (HKMA) Dr. Chow Pak-chin believes the 9,372 Chinese medicine doctors in Hong Kong ought to be included in the calculation. An adjusted ratio including Chinese medicine doctors would bring the ratio to 2.67, according to HKMA in 2011. For comparative purpose though, other numbers would likewise have to be revised to include their Chinese and alternative medical practitioners.
Comparing apples to apples, 1.8 vs. 3.6 suggest Hong Kong is operating below OECD standards though the Government claims there is no universal standard on such a ratio.
In an interview with Harbour Times, both Dr. Leung and Dr. Chow expressed the belief that the private medical sector had sufficient doctors to serve Hong Kong. Deducting the 5,611 doctors working in the Government and HA, there are around 6,000 doctors (excluding medical professors and research professionals) in the private medical sector serving around 70% of the total out-patient visits in Hong Kong every year. The Government has no figures concerning the number of patients visiting private clinics, rendering a numerical analysis on the manpower situation in the private medical sector impossible.
However, an official soundbite may shed some light on the situation. During the meeting of the LegCo’s Panel on Health Services last month, Secretary for Food and Health Dr. Ko Wing-man said to Mr. Michael Tien (GC- New Territories West, New People’s Party), “we [the Administration] haven’t made the best use of doctors in the private sector…” But this small admission of a possible underutilisation of doctors in the private sector is not the only needle poking the idea of a doctor shortage bubble.
The care is there
Dr. Pierre Chan, a specialist of gastroenterology and hepatology in Ruttonjee Hospital and Vice President of the Hong Kong Public Doctors’ Association, holds another view on the alleged doctor shortage in Hong Kong. “I have not seen a case which a patient was denied medical care in Hong Kong”, he says and contrasts with the example of United States. Excluding emergency treatments, appointments to doctors can only be made after patients’ ability to pay has been assessed. In Hong Kong, payments will only be required after medical services are delivered and this has led to an accumulation of bad debts when patients desert their bills. Patients, regardless of their financial backgrounds, are taken care of in life-threatening cases in Hong Kong and the public hospitals are charging a low fee many find affordable.
Dr. Chan believes no patients in Hong Kong fail to receive medical care when they need it most, a point that resonates with Mr. Alex Lam, the Vice President of the Hong Kong Alliance for Patients’ Organisations. Advanced medical technology is also in place for the high-end market, targeting wealthy patients. Dr. Chan considers patients from all walks of life well taken care of in the current medical system.
The long waiting time for patients in certain public hospital clusters is certainly unpleasant but rarely poses an immediate risk to life and limb. Dr. Chan questions the existence of doctor shortage in Hong Kong at large. Those waiting for treatment may differ, believing, to appropriate a legal term, that healthcare delayed is health care denied.
How long is too long
Amid the ongoing debate of a doctor shortage problem in Hong Kong in general, the public outcry concerning the long waiting time in certain public hospitals is an absolute fact. But there seems to be no consensus on waiting times when Harbour Times asked doctors and representatives from patients’ organisation alike. “Waiting time varies for different people, so there’s no such thing as an ideal waiting time”, says Mr. Lam from the Hong Kong Alliance for Patients’ Organisations.
Dr. Chan predicts HA will undertake a huge reputational risk if it sets a standard waiting time – and doesn’t meet it. However, without a standard waiting time, the blame for delays falls wholly on the frontline doctors trying to meet unarticulated and shifting standards of anxious patients.
Lacking the incentive to change
It might be a relief that the long waiting time is only a phenomenon occurring in certain clusters, namely Kowloon East and New Territories East (see Graph 2). However, the resource allocation to the clusters highlights an inconvenient truth. Annual recurrent funding to HA is on the rise: $42 billion was approved for the year 2012-13 by LegCo, a 6.7% increase from the previous year and 11.8% the year before. Resource allocation among clusters has remained more or less the same in recent years (see Graph 3). Interesting to note, Kowloon East receives the least proportional funding from HA though it has a higher population than Kowloon Central and longer waiting times than Hong Kong East and West.
Criticism from Dr. Leung and Dr. Chan is acute. They both see no incentive to change for the HA and Government. The rather easy funding to HA by LegCo is one of the reasons, Dr. Leung suggests. When asked about the ambiguous funding rationale to the clusters, Dr. Leung says “they [HA officials] are not trying to reason with you, HA has no incentive to change! It remains the same especially when the Government is not regulating it.” Dr. Chan has an explanation to the statement. He claims the Government believes it more important to settle the housing and education problems for the time being.
Contracting flows downhill
Dr. Chan has a strong view on the malfunctioning public health system and this is not the first time he has criticised the contracting system of our public health care services. The Government first contracts the public health care services to HA; HA then contracts the resource management to the clusters, then to the public hospitals, then to the department heads and then to each specialty. He believes a big chunk of the resources are dissipated in bureaucracy in this multiple layered contracting system.
The one-off funding to HA and the contracting system have together made supervision difficult. Another revelation he makes concerns manpower planning. In spite of increasing funding every year and increasing health expenditure, the medical quality of the public hospitals has stagnated. Dr. Chan says hiring decisions arise from the budget and not from the perspective of patients, nor from the level of service quality HA wants to achieve. “Nothing can be done unless HA undertakes major reform.” His hope might be realised this fall when the Hospital Authority Review Steering Committee, created in last August, completes its review.
The road to waiting list hell is paved…
In search of a solution to the so-called doctor shortage problem in public hospitals, Dr. Leung Ka-lau points a flawed solution undertaken by the Hospital Authority, arising from good intentions. The intention was to have more doctors take up part time work in hospitals to relieve workloads and reduce waiting times for procedures.
Since 2011, part-time doctors are paid 70% of the full-time hourly salary of their corresponding ranks. The compensation can reach 100% of the full-time wages if part-time doctors take up on-call duties. The latest figure obtained from HA shows that a total of 313 part-time doctors are working in the public hospitals as of last November. The figure is equivalent to around 119 full-time doctors.
Viewing the part-time compensation as a sort of overtime pay scheme in which doctors from all sectors (including doctors working in the public hospitals) are free to participate, Dr. Leung criticises the 70% as an improper means of compensation and a violation of the market mechanism. He argues the most direct and easiest solution to a manpower crisis in all institutions is first to offer overtime pay to employees or hire an extra staff. Both are normally calculated from the full-time wage, so HA’s part-time compensation should be more or less the same with the full-time wage and not 70%. He also argues that night shifts in the A&E department should even be compensated at 250% of the full-time wages. “If you [HA] don’t try these methods [reasonable overtime pay]…it is difficult to claim there is a shortage of manpower”, says Dr. Leung. He believes by paying an overtime pay at 100% of the full-time wage, there will be a major boost in the number of part-time doctors.
In other words, if you have a normal wage, instead of the current substandard wage, you will quickly discover if you have a real shortage or not. He believes the problem now isn’t a shortage of doctors, but rather inferior wage levels that can’t attract enough doctors.
Overseas doctors, jumping through hoops- of bureaucratic fire
Many have suggested recruiting more non-local doctors but the proposition has received
http://harbourtimes.com/2015/10/13/is-there-a-doctor-in-the-house/
