Strengthening Primary Care in Hong Kong: Fostering Continuity of Care from a Health System Perspective Margaret K Ho *, Msc Public Health
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COMMENTARY Strengthening primary care in Hong Kong: fostering continuity of care from a health system perspective Margaret K Ho *, MSc Public Health Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom * Corresponding author: [email protected] Hong Kong Med J 2020;26:543–5 https://doi.org/10.12809/hkmj198368 In 2018, Hong Kong was reported to have most incurs substantial out-of-pocket payments making efficient health system globally.1 However, there are it unaffordable for some. The Elderly Health Care large imbalances: while 90% of in-patient care is Voucher Scheme, as a public-private partnership, managed by the public sector,2 70% of primary care restructures health financing equitably to provide consultations occur privately.3 monetary incentive for elderly patients to seek The current primary care system in Hong private providers. This reduces the burden on the Kong remains underdeveloped, fragmented, and public sector, not only at the primary level but also inefficient: only 60% of the population have a regular at higher levels of care owing to better gatekeeping. care source.4 “Doctor-shopping” culture, and a This also improves quality of service delivery. Private disproportionate emphasis on acute episodic care, providers are vetted before being included into the have limited the development of lasting patient- scheme to ensure safety and quality. Currently, there provider relationships.3 This is exacerbated by are over 4000 providers covering all districts in the primary care providers’ limited gatekeeping roles, city, maximising service coverage and accessibility leading to poor continuity of care in an overburdened for elderly patients, who are often financially public system.2 Furthermore, Hong Kong faces a vulnerable.9 rapidly ageing population with the proportion of There has been some improvement in relational population ≥aged 65 expected to reach 30% by 2039.5 continuity, that is, sustaining lasting patient-provider Health systems depending predominantly on relationships. Among users registered under the primary care have better health outcomes, such as Electronic Health Records Sharing System (eHRSS) improved access to care and decreased avoidable with multiple claims, 75% attended only one medical mortality.6 Continuity of care is a crucial aspect provider, accounting for approximately half of total of a good primary care system, assuring a patient- eligible users registered on eHRSS.7 However, in provider relationship that extends over time and a 2011 review, 69% of users spent their vouchers beyond illness episodes.7 on acute episodic curative services, and only 21% This commentary focuses on strategies to of total claims represented consultations for the foster continuity, as part of strengthening Hong monitoring of chronic conditions.10 In a separate Kong’s primary care system. Three relatively new study, 66% claimed that “the scheme did not change interventions are examined to address the three their health seeking behaviours on seeing public or types of continuity: relational, management, and private healthcare professionals”.11 informational.8 There needs to be more targeted incentives towards continuity of care. This could start straight from the enrolment process by encouraging patients Relational continuity: reviewing to register with and maintain attendance at one the Elderly Health Care Voucher trusted care provider. Since this health financing Scheme strategy was successful in attaining high utilisation, Launched in 2009, the Elderly Health Care Voucher other possible modifications could be to devote a Scheme provides an annual allowance of HK$2000, portion of the vouchers to be used on preventive care, in the form of vouchers, for citizens aged ≥65 years as well as to have discounted consultation fees for to use on private outpatient services.9 It aims to patients if they continuously attend the same primary provide financial and social protection for elderly care provider. Although continuity may initially be patients and to encourage them towards a regular based on monetary gain, it would hopefully foster source of care best suited to their needs.9 a genuine, trusting patient-provider relationship in Although primary care is more frequently the long run, as providers would be more familiar managed privately, most likely due to greater with patients over time. This strategy would likely accessibility and shorter waiting times, it also be helpful for patients with chronic illnesses who Hong Kong Medical Journal ©2020 Hong Kong Academy of Medicine. CC BY-NC-ND 4.0 543 # Ho # benefit greatly from a regular source of care. It would care.15 This guidance should be fostered during also be considerably advantageous for system load education and training to promote an appreciation balance as care for chronic illnesses usually require for integration in the health workforce early on. more resources. To address budgetary concerns, the Periodic reviews of CHCs would be necessary to government recently expressed willingness to invest ascertain that the appropriate care is being delivered more funds, if needed, to improve the scheme.12 efficiently. These reviews may be done by considering Regular monitoring would be needed to ensure the health outcome measures such as patient mortality effectiveness of such a change. and morbidity, admission and readmission rates, as well as patients’ perspectives. Management continuity: integrating the medical workforce Informational continuity: in Community Health Centres expanding the Electronic Health Aside from improving private care, it is necessary Records Sharing System to ensure that public care is well-suited to citizens’ Achieving relational and management continuity needs. In response to this, Hong Kong developed requires seamless information sharing which requires Community Health Centres (CHCs), public one-stop the availability and use of patient information, that polyclinics.13 To date, three CHCs in population- is, information continuity.7 In 2016, Hong Kong dense districts are in operation, with plans for launched the eHRSS, an electronic platform for more.13 Management continuity is emphasised with public and private healthcare providers to access the appropriate provision of complementary care consenting patients’ health records, including results types for consistency of care.7 This is particularly of investigations as well as management plans.15 It important for patients with chronic illnesses who aims to provide smooth information transfer so may require a variety of services. that practitioners can draw on patient records to Members of the health workforce, including coordinate care. doctors, nurses, and allied health professionals, work This technology has many advantages. Having together at CHCs to offer medical consultations, a single reporting system with patient records readily health risk assessments, and preventive care.13 available allows practitioners to respond to patients’ Service delivery is tailored to community needs. needs immediately and decreases likelihood of For example, as diabetes is prevalent in Hong Kong, repeated tests or treatments being done which can diabetic eye and foot checks are provided.14 Some reduce efficiency.16 A smooth transition of care can CHCs have self-service stations for patients to take be achieved if patients attend to multiple providers their own blood pressure, weight, and height, to or change practitioners. By providing patients with increase patients’ control over their own health.14 access to their official health records, this allows Having regular and convenient access to a CHC for greater transparency and accountability in a with a diverse scope of services will likely prompt system where information asymmetry is a challenge. patients to engage in primary care more frequently. On a community level, eHRSS supports disease Consistent monitoring of their health will also allow surveillance for public health security.15 for any problems to be addressed immediately. One of the biggest challenges for eHRSS is lack However, having different healthcareof uptake. Although it has been well-received and is professionals working at a CHC does not necessarily relatively new, only 10% of the general population mean that integration or interprofessional and 40% of medical professionals are registered (as collaboration will automatically be achieved. One of April 2018), with the latter citing high costs of barrier is the lack of understanding within the implementation and training as reasons for non- workforce on the roles of each professional, especially participation.2 This lack of use greatly limits its of those in allied health fields. In fact, an interview effectiveness. with a local professional health organisation revealed On lack of patient uptake, there is potential that “…trainees don’t understand the practice and for eHRSS to provide a patient-centred platform. role of other professionals (ie, allied health) …”.2 This In addition to current access to their own records, may lead to fragmentation or duplication of services this platform could include services for appointment delivered. booking and personalised information on disease To address this challenge, good governance management and prevention. Patients could also is key. For smooth horizontal and vertical contribute to their own records by providing integration, there needs to be clear definition on updates and questions before consultations. This the responsibilities of different