Is there a doctor in the house?

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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 a cold reception from the medical sector. The Medical Council of Hong Kong is the statutory body to register medical practitioners and handle complaints. Overseas doctors are required to take the Council’s licensing examination after completing not less than five years full time medical training (including internship) and holds a medical qualification acceptable to the Council. The examination consists of three parts, namely the Examination in Professional Knowledge (Part 1), Proficiency Test in Medical English (Part 2) and Clinical Examination (Part 3).

Content of the examination is set by the two medical schools, HKU and CUHK, to reflect the examinations taken by the local medical graduates. Applicants can only sit for the Clinical Examination (Part 3) after passing Part 1 and 2. Applicants, upon passing all the exams, have to finish an internship in a hospital for a year regardless of the previous medical experience he or she has obtained.

The passing rate is said to be around 10% for passing all parts of the process, a figure that Dr. Chow Pak-chin sees as quite high by world standards. But taking Part 3 alone, the passing rate ranges from 20-50% while in UK, the passing rate for their final part of the licensing exam ranges from 60-70%. Critics have said that the licensing examination of the Medical Council tests very basic medical knowledge, a barrier to senior doctors who have left school for so long. Dr. Chow agrees and proposes to arrange tutorials for applicants to prepare better for the examinations.

There have been changes in the licensing exams across the years. Before 1996, graduates from some medical schools in UK, Ireland and some Commonwealth countries were exempted from taking the exams. No exemptions were allowed after 1996. The Medical Council previously only conducted the licensing exam once a year.  Under pressure, they have consented to increase the chances to take it each year – from one to … two.

Sneaking in through the back door

The HA’s initiative to use the Limited Registration as a mean to circumvent the examination for extra doctors in the short-term has triggered much dissent among doctors. Limited Registration allows overseas medical professionals to practise medicine in Hong Kong for a year after meeting particular criteria. Applicants do not need to go through the licensing examination and they can renew their registration for another year.

Since 2011, HA has been using Limited Registration to employ more doctors in the public hospitals. An HA Task Force of Limited Registration Scheme was set up in 2011 to screen the applications before sending to the Medical Council for approvals. In most cases, applicants have to be fluent in Cantonese, have three years of clinical experience and have attained a qualification comparable to that of the Hong Kong Academy of Medicine. HA received 160 and 72 applications in 2012 and last year. 14 applications were passed to the Medical Council and 13 were approved. Up to November 2013, 6 out of the 72 applications were sent to the Council and all approved.

Dr. Leung Ka-lau and Dr. Chow Pak-chin oppose the Limited Registration as a mean to solve the manpower shortfall claimed by HA. Dr. Leung reiterates that implementing a proper overtime compensation should be the first step before seeking to recruit overseas doctors. “If HA can show that even setting the overtime compensation at 100% or more of the full-time wage for part-time doctors and the problem of doctor shortage still lingers, then recruiting overseas doctors could be one means [of addressing the problem].” Dr. Chow on the other hand, sees the practise destroying the medical system in Hong Kong. He believes HA has obtained little benefit from the small number of approved cases each year, and has tarnished a system that has been working effectively for many years. “Limited Registration is not for overseas doctors to come to work in Hong Kong for long periods of time without taking the licensing exam. This is not the intention.” He sees the scheme is more for research and education purposes.

Those against the Limited Registration include Mr. Alex Lam from the Alliance for Patients’ Organisations, saying ”we are aware of the role of the Medical Council to enhance medical quality, so by-passing the licensing examination, or making it too lenient, will not fit its role.”

A group of juris doctor students in CUHK generated a research paper on Limited Registration in 2012. Research outcome shows that though the scheme can be a short-term measure to alleviate the long waiting times of patients, it is not a solution to the root of the doctor shortage problem in the public hospitals. One of their suggestions asks for a review of the composition of the Medical Council. Currently with 4 laymen as Council members, the General Medical Council in the UK has half its Council members from the non-medical sector. Among other professional regulatory bodies in Hong Kong, the Hong Kong Institute of Certified Public Accountants has the same number of 4 lay members. The Veterinary Surgeons Board of Hong Kong and the Nursing Council have 2 and 3 laymen respectively.  The addition of  non-doctors would ideally increase representation of the views of the general public and improve transparency.

Change is the cure

A Steering Committee on Strategic Review on Health Care Manpower Planning and Professional Development was created in January 2012. In response to a LegCo oral question last year, Secretary for Food and Health Dr. Ko Wing-man answered, “it is expected that the review will be completed in 2013 and the Steering Committee will come up with recommendations on how to cope with anticipated demand for healthcare manpower, strengthen professional training and facilitate professional development, with a view to ensuring the healthy and sustainable development of our healthcare system…” While we closing quickly on the end of the first quarter of 2014, a report is yet to be seen.

An overall doctor shortage in Hong Kong might still be debated but the long waiting time in few public hospitals is very real. While measures have been taken to attract more part-time doctors and minimise turnover, the crux of the problem lies with the HA resource allocation. Demand for change has been high for years and there should be no more delays.

HA has attributed part of the reason for the shortfall of doctors in public hospitals to a dwindling number of medical graduates in recent years. The tightening Government budget after the SARS outbreak in 2003 has seen the decline of quota for local medical school students. To increase the number of medical graduates, the Government has set aside an extra $200m for the triennial cycle starting from 2012 to increase the number of first-year first-degree places in medicine by 100 to 420 each year. It is expected to see an increase in the number of local medical graduates from 250 to 320 in 2015-16 and 420 in 2018-19. In a few years from now, the long waiting time problem might be solved. Fingers-crossed.