Public hospital crisis due to structural problems
Updated: 2019-03-12 06:00
Ho Lok-sang argues that nurturing the private sector to alleviate the burden on public sector causes serious manpower shortage in the latter
It is well known that our public hospitals are in a state of crisis. Morale among medical staff is low. The turnover rate of medical staff is high. Queues for services are long. Clinical time with patients is short. Medical incidents have become more frequent. Public ratings for our publicly funded healthcare system has fallen to a historical low.
The SAR government has almost doubled its funding for the Hospital Authority over the period from 2010 to 2018, and early in the year, allocated an additional HK$500 million to deal with the winter flu epidemic. The number of physicians per 1,000 population had been rising secularly. At the inception of the Hospital Authority back in 1990, we had about 1.1 doctors per 1,000 population. Today, we have about 1.9. But people were quite happy with our public healthcare system then. We should have all kinds of reasons to expect much better services. But the reality is quite different. Why?
I recall that during the early years of the Hospital Authority, we had another crisis, and that was the low utilization rate in our private hospitals. The situation now is exactly the opposite. Dr Shea Tat-ming, member of the Hong Kong Medical Council, wrote in an article that currently 6,300 plus or 45 percent of Hong Kong's doctors are in the public sector and they look after 90 percent of Hong Kong's patients. Some 7,000 or 55 percent, on the other hand, are in the private sector and they serve 10 percent of the Hong Kong population. Shea thinks that there is no shortage of doctors overall. In comparison with 1990, certainly he is right. But statistics show that among OECD countries, the average was 2.9 back in 2013, and that is a lot higher than that in Hong Kong. Still Hong Kong should have improved over 1990 given the infusion of resources and the much larger doctor-to-population ratio.
I would argue that the whole strategy of nurturing the private sector in order to alleviate the burden on the public sector is at the root of the structural medical staff shortage in Hong Kong. The situation today is entirely to be expected. A study in Canada back in 2007 from Wellesley Institute concluded: "Solid evidence shows that more for-profit finance would increase administrative costs and decrease equity. More for-profit care delivery would also raise costs, while decreasing equity and risking quality. So-called public-private partnerships appear to increase overall costs." A more recent article published in 2015 carried the title: "Evidence is in: privately funded healthcare doesn't reduce waiting times", and it documented the evidence. Readers can easily refer to these studies on the internet.
Think about the consequences of an enlarged for-profit private hospital sector. Not only will they compete away the most experienced doctors and nurses from the public hospitals, but they also will leave the more complicated, costly-to-handle cases as well as chronic patients in the public hospitals. This is exactly what we are observing today in Hong Kong. Our waiting times have got longer notwithstanding more private hospitals.
From 2001 to 2017, private hospital beds in Hong Kong rose 60 percent from 2,903 to 4,644. Public hospital beds in Hong Kong dropped more than 3 percent from 29,243 to 28,329. The drop over 16 years is a big surprise to me. During the time our population had gone up more than 10 percent, and the median age of the population has gone up from roughly 36.2 (2000) to 43.5. We have aged considerably and increased in numbers considerably. Yet, incredibly, our public hospital bed numbers shrank! The dramatic growth of our private healthcare sector did not reduce the burden of care on our public healthcare system.
I also recall that the Hospital Authority had been squeezing "productivity enhancement" from its staff year in year out for quite a number of years. I am not sure if it is still doing that. But at the time when I was closely watching developments in the Hospital Authority I was wondering how this could go on. Healthcare is a labor-intensive, skill-intensive enterprise. "Productivity enhancement" to a large extent means asking the same staff to do more and more work.
Back in 2017, I had already warned, in this column, that the '"health services industry" drive could bleed our public hospitals (March 14, 2017). I started that article thus: "I am truly worried about a vicious circle in the making: More and more Hong Kong people patronize private hospitals because our public hospitals are not up to the mark; private hospitals profit from the increased demand and draw more skilled manpower to work for them and services at public hospitals decline further, aggravating the exodus of patients to private hospitals."
With the total number of hospital beds in Hong Kong rising only 2.6 percent from 2001 to 2017 in the midst of population increase in excess of 10 percent and fast aging, our private hospitals are enjoying a very high utilization rate; our public hospitals are suffering from a very high over-utilization rate. We have to face it. Our problem is structural.
(HK Edition 03/12/2019 page9)