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Primary healthcare will be the best way forward

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Primary healthcare will be the best way forward

By Zorina Kwong and Kacee Ting Wong

An issue of great concern is whether Hong Kong’s medical and financial resources could be stretched to the maximum extent to maintain an over-burdened treatment-oriented and hospital-based healthcare system in the long run. Disappointingly, the answer is no. In order to make our healthcare system sustainable, we must ease the excessive burden on the hospital-based public healthcare system. It is an unassailable fact that a primary healthcare system offers a way out of the impasse.

In his 2022 Policy Address, Chief Executive John Lee Ka-chiu took an important step in the right direction by providing a medical roadmap showing how the promotion of primary healthcare could make Hong Kong’s healthcare system more sustainable. Primary healthcare is the first point of contact for individuals and families in a continuous healthcare process in the community, which entails the provision of accessible, comprehensive, continuing, coordinated and person-centered care. It serves as a gateway to specialized secondary and tertiary healthcare in hospital and institution settings (Primary Healthcare Blueprint, Health Bureau, December 2022).

Back in 1990, the Working Party on Primary Healthcare published a report with 102 recommendations. One of the recommendations was the establishment of a statutory primary healthcare authority to oversee the provision of primary healthcare in Hong Kong (Medical and Health, by Leung Man-fu, in The Other Hong Kong Report, Choi Po-king and Ho Lok-sang (eds.) (HK: Chinese University Press, 1993)). But this recommendation has been left on the shelf for many years. The long waiting game will soon come to an end with the establishment of the Primary Healthcare Commission next year (Establishment of the Primary Healthcare Commission, by F.C. Pang and S.S. Lai, in Hong Kong Medical Journal).

Although most of the recommendations of the working party have been relegated to the backburner, the Hong Kong Special Administrative Region government has not turned a blind eye to primary healthcare. In March 2008, what was then termed the Food and Health Bureau published a consultation paper on primary healthcare. In response to the consultation paper, Sian Griffiths and Jeff Lee have drawn attention to the established mainstream view in the medical world that a modern healthcare system needs to be based on primary healthcare (Sian Griffiths and Jeff P.M. Lee, Developing Primary Healthcare in Hong Kong: Evidence into Practice and the Development of Reference Frameworks, in Hong Kong Medical Journal).

It’s worth noting that Our Hong Kong Foundation also supports the need to build a primary healthcare system. In its 2018 report, the foundation noted that over half of people in hospitals suffered from problems that could be dealt with in community clinics (Fit for Purpose: A Healthy System for the 21st Century, in Our Hong Kong Foundation). Therefore, public health functions of health protection, health promotion, disease prevention, surveillance and response, and emergency preparedness need to be integrated with primary and specialist care (ibid).

Financially speaking, public spending on healthcare will increase rapidly in the future not because of rising population numbers but because of aging. One study estimates that it was 8.5 times more expensive to treat those aged 75 or over than to treat those aged 15-64 (Fixing Inequality in Hong Kong, by Richard Wong (HKU Press, 2017)). From a manpower perspective, public expenditure on healthcare should not be cut because it is an indirect investment in human capital and labor productivity.

The over-reliance on a hospital-based healthcare system has resulted in inadequate public expenditure on primary healthcare services. As evidenced by Hong Kong’s Domestic Health Accounts in 2019-20, only around 17 percent of the total public current health expenditure was spent on primary healthcare, with the remaining 83 percent spent on secondary and tertiary healthcare services (F. C. Pang and S. S. Lai, ibid). As Pamela Tin correctly pointed out, during the fifth wave of the COVID-19 pandemic, the hospital-centric system struggled to meet the demands of non-COVID-19-related care despite service availability in the private sector (Better Primary Healthcare Needed During and Beyond the Pandemic, by Pamela Tin, in Our Hong Kong Foundation).

Tin also argues that a stronger primary healthcare ecosystem could have pushed for quicker vaccination uptake and education during the pandemic. Because of the weak primary healthcare system in the city, many old people remained unvaccinated. If the vaccination rate had increased, the COVID-19 death rate would have been reduced. As a result, we should strengthen the primary healthcare system in order to enhance our disease prevention capability.

Recently, the death of two intellectually disabled brothers in Sau Mau Ping Estate has further prompted calls for better community services. Another tragedy occurred in a private flat in Happy Valley in June 2023. Firefighters found an extremely weak and dehydrated 75-year-old woman in her flat. Her younger brother and carer, 71, was found dead in the bedroom. Perhaps District Health Centers should play a greater role in monitoring these hidden patients.

When Secretary for Health Professor Lo Chung-mau introduced the Primary Healthcare Blueprint in late 2022, he focused on prevention and early detection and diagnosis. The major directions of primary healthcare reform include developing a community-based primary healthcare system to further develop the district-based, family-centric community healthcare system based on the service model of district health centers as well as strengthening the concept of “family doctor for all”.

Some of the recommendations of the Primary Healthcare Blueprint include establishing a two-way referral mechanism between primary healthcare services and specialist and hospital services; adopting the co-payment principle in providing government-subsidized primary healthcare programs; reinforcing primary healthcare manpower; and improving data connectivity and health surveillance. There is not the slightest shadow of doubt that the government has strong determination to put the above recommendations into practice. As an indication of its determination, the Chronic Disease Co-Care Pilot Scheme will be introduced in November 2023 to take preventive measures to combat chronic disease.

Zorina Kwong, formerly a registered nurse, is the community pro-bono services senior adviser of Chinese Dream Think Tank.

Kacee Ting Wong is a barrister, part-time researcher of Shenzhen University Hong Kong and Macao Basic Law Research Center, and chairman of Chinese Dream Think Tank.

The views do not necessarily reflect those of China Daily.

【CDTT Newspaper Article】Zorina Kwong and Kacee Ting Wong:Primary healthcare will be the best way forward (China Daily HK Edition, 27 Nov 2023)

https://www.chinadailyhk.com/article/363417#Primary-healthcare-will-be-the-best-way-forward

Chinese Dream Think Tank is a non-profit Hong Kong-based organization working with skilled volunteers, experts and professionals who are passionate about telling the China story well.

This article is reproduced by Kwun Media with the consent of China Daily.

中國夢智庫| 特區的「基層健康服務」系統 

特區財政預算可否應付以治療為導向、以醫院為基礎的醫療體系的持久發展?這是社會各界一直關注的議題。從長遠來看,現行的醫療制度將導致政府財政負擔過重。為確保特區的醫療體系保持穩定可持續性,大家須想辦法減輕以醫院為基礎的公共醫療體系,防止醫療體系受壓過度。一個不爭的事實,「基層健康服務」系統是解決辦法之一。

在《2022年施政報告》中,行政長官李家超先生推廣基層醫療,特別重視如何使特區醫療體系具備可持續性,他正確指出:「基層醫療健康服務提供模式將逐步轉變為地區為本的社區醫療健康系統,以推動現時醫療系統的整體模式轉變,並扭轉現時「重治療、輕預防」的觀念…」。「基層健康服務」可促進市民管理各人健康、提高基層醫療健康服務重要性與讓市民更易獲得所需基層醫療服務的第一級接觸點,這需要提供可及的、全面的、持續的、協調的與以人為本的護理。透過指定慢性疾病協定護理流程及訓練有素的基層家庭醫生,縱向整合及銜接第二層和第三層醫療服務,並進一步強化「一人一家庭醫生」概念。增加醫療服務發展的整體策略規劃、協調,和縱向與橫向融合(註1)。

早於1990年12月,「健康與醫療發展諮詢委員會基層醫療工作組」(「基層醫療工作組」)發表《人人健康,展望將來》報告書。報告書肯定基層醫療的重要性,並提出102項發展建議(註2)。其中一項建議是成立法定「基層醫療管理局」,監督特區基層醫療服務的進展(註3)。但上述建議多年來未被拓展。漫長歲月的等待期隨著明年會落地的「基層醫療健康管理局」(註4),即將迎來曙光(註5)。

雖然只有少數「基層醫療工作組」的建議得到引用,但特區政府一向都對基層醫療保持非常重視的態度。2008年3月,「食物及衛生局」發表《掌握健康,掌握人生——醫療改革諮詢文件》(註6)。葛菲雪教授(Sian Griffiths)與Jeff Lee積極回應了這份改革諮詢文件,兩位學者正確指出,現代醫療保健系統需要以基層健康服務為基礎,這是醫學界的主流觀點(註7)。

大家注意,一直以來《團結香港基金》(「基金會」)也表示支持在特區建立一個完善的基層醫療體系。在2018年的報告中,基金會明確指出:「醫療體系的問題是有目共睹。有數據顯示,若有適當的門診照護(包括基層醫療、社區護理等),公立醫院有近一半的入院個案是可避免的…」(註8)。因此,保護健康、促進健康、疾病預防、監測和應對與應急措施等公共衛生職能需要與基層醫療服務與專科護理事項相結合(註9)。

 關係財務安排,隨著人口增長,居民老齡化是特區未來公共醫療保健支出的大項目。根據一項研究估計,治療75歲或以上的病人比治療15-64歲病人所產生的費用貴8.5倍(註10)。從人力資源角度來看,因為針對公共醫療保健方面的投入對人力成本與勞動生產率有間接的促進作用,所有,公共醫療保健方面的支出不應被削減。

過度依賴以醫院為本的醫療體系會攤薄投入基層醫療服務的公共開支預算。「2019-20年度香港本地醫療衞生總開支帳目」顯示,目前公共醫療衛生總開支中只有約17%用於基層醫療服務,其餘83%用於第二層與第三層醫療服務(註11)。正如「基金會」醫療及社會發展研究主管田詩蓓博士正確指出,雖然私營醫療機構在第五波COVID-19期間提供了一定的服務,但以醫院為中心的系統仍未能滿足當時非COVID護理的需求(註12)。

 田詩蓓博士認為,在疫情大流行爆發期間,更完備的基層醫療服務生態系統可更快的推動疫苗接種效率與相關教育(註13)。由於特區的基層醫療服務系統尚未完善,當時許多老年人仍未接種疫苗。可以說,如果疫苗接種率提高,COVID-19 死亡率就會降低。因此,特區應加強基層醫療服務體系,以提高特區全體居民的疾病預防能力。

近日,兩宗新聞令人心痛。早前,秀茂坪邨兩名智障兄弟不幸去世。2023年6月,消防員在位於跑馬地一間私人公寓發現一名極度虛弱與嚴重脫水的75歲婆婆,她 71 歲的弟弟與外傭被發現死在臥室內(註14)。因此,「社區衛生中心」應能在監測社區隱藏病人方面發揮更大作用。上述例子顯示,進一步推動改善基層醫療服務系統有燃眉之急。

 醫務衞生局局長盧寵茂教授在2022年底公布《基層醫療健康藍圖》(「藍圖」)時表示:「… 加強香港基層醫療服務,以預防為重、社區為本、家庭為中心、早發現早治療為策略,並以改善市民整體健康狀況、提供連貫全面的醫療服務、建立可持續的醫療系統為願景…」。「藍圖」的重點改革方向是建立社區基層醫療系統,強化一人一家庭醫生概念,務求令市民不用動輒到醫院求醫或接受健康管理;當局同時加強管理,完善基層醫療服務與專科、醫院之間的雙向轉介流程,以及整合基層醫療健康資源,優化長者醫療券計劃與其他資助服務(註15)。

 「藍圖」其他建議包括:在基層醫療服務、專科醫生與醫院服務之間建立雙向轉介機制,在提供政府資助的基層醫療計劃時採用共同付款原則,加強基層醫療人力,改善數據連接與健康監測(註16)。毫無疑問,特區政府有堅定的信心與決心將上述建議付諸實踐。舉例說明,為採取預防措施完善對抗慢性病體系,政府將於2023年11月推出「基層醫療-慢性疾病共同治理先導計劃」。

事實與資料來源已核查

註 1: 醫務衛生局「基層醫療健康藍圖 附篇」2022年12月,第10頁 available at: https://www.primaryhealthcare.gov.hk/bp/cms-assets/Primary_Healthcare_Blueprint_Supplement_Perfect_Binding_Chi_6d47c606ea.pdf

註 2: 同上,第6頁

註 3: Leung Man-fu「Medical and Health」in Choi Po-king and Ho Lok-sang (eds.) The Other Hong Kong Report, Chinese University Press 1993 at p 224

註 4: 新聞公告「基層醫療健康專員履新」07.11.2022, 第三段 available at: https://www.info.gov.hk/gia/general/202211/07/P2022110700196.htm?fontSize=1

註 5: F.C. Pang and S.S. Lai「Establishment of the Primary Healthcare Commission」Hong Kong Medical Journal Vol.29, No.1, February 2023 at p 6

註 6: 食物及衛生局「“掌握健康掌握人生” 醫療改革公眾諮詢 第一階段公眾諮詢報告」Feb 2009 立法會CB(2)819/08-09號文件 available at: https://www.legco.gov.hk/yr08-09/chinese/panels/hs/papers/hs0209cb2-819-c.pdf

註 7: Sian Griffiths and Jeff P.M. Lee「Developing Primary Healthcare in Hong Kong: Evidence into Practice and the Development of Reference Frameworks」Hong Kong Medical Journal Vol.18, No.5, October 2012 at p 429

註 8: 團結香港基金「以人為本 縱橫整合 香港醫療體系研究報告」03.12.2018 available at: https://www.ourhkfoundation.org.hk/zh-hant/media/90/團結香港基金/以人為本-縱橫整合

註 9: Our Hong Kong Foundation「Fit for Purpose: A Healthy System for the 21st Century」30.11.2018 at p 3

註 10: Richard Wong「Fixing Inequality in Hong Kong」 HKU Press 2017 at p 233

註 11: 同前,註 5

註 12: Pamela Tin「Better Primary Healthcare needed during and beyond the pandemic」Our Hong Kong Foundation at para 4 (English only) 12.09.2022 available at: https://www.ourhkfoundation.org.hk/zh-hant/report/36/醫療及老齡化/better-primary-healthcare-needed-during-and-beyond-pandemic

註 13: 同上

註 14: Fiona Chow and Clifford Lo「Hong Kong welfare chief pledges more support for carers, after 2 intellectually disabled brothers believed to have starved to death in mother’s absence」SCMP 22.09.2023 available at: https://amp.scmp.com/news/hong-kong/law-and-crime/article/3235546/2-middle-aged-hong-kong-brothers-intellectual-disabilities-believed-have-starved-death-after-mother

註 15: 政府新聞網「基層醫療健康藍圖公布」19.12.2023 available at: https://www.news.gov.hk/chi/2022/12/20221219/20221219_164421_392.html

註 16: 同上

文:鄺桂嬋
前註冊護士
「中國夢智庫」地區事務義務工作高級顧問

文:丁煌
深圳大學基本法研究中心兼職研究員
經民聯港島支部主席,「中國夢智庫」主席
國際公益法律服務協會顧問委員會成員
香港法學交流基金會副主席
全國港澳研究會會員

 《中國夢智庫》是一間扎根特區的非牟利團體;與心存熱誠的資深義工、專家與職業專業人士們合作,攜手「說好中國故事」。

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