Strengthening Primary Care in Hong Kong: Fostering Continuity of Care from a Health System Perspective Margaret K Ho *, Msc Public Health

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

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 actors, and how could be preceded by appropriate training sessions each functions as part of the health system.15 All for patients, especially elderly ones. In this way, actors should be held publicly accountable for providers would be able to review their input and their respective tasks to ensure a high standard of provide more targeted and efficient care, which is

544 Hong Kong Med J ⎥ Volume 26 Number 6 ⎥ December 2020 ⎥ www.hkmj.org # Strengthening primary care in Hong Kong # crucial considering limited consultation times. By 4. Wong SY, Zou D, Chung RY, et al. Regular source of care supporting patients to engage with practitioners for the elderly: a cross-national comparative study of Hong and take an active role in their own health, this Kong with 11 developed countries. J Am Med Dir Assoc could encourage co-production of health using 2017;18:807.e1-8. 5. Census and Statistics Department, Hong Kong SAR an innovative and patient-centred approach. This Government. Hong Kong Population Projections 2017- would hopefully attract more patients towards the 2066. 2019. Available from: https://www.statistics.gov.hk/ eHRSS. For healthcare providers, the provision of pub/B1120015072017XXXXB0100.pdf. Accessed 15 Feb free training could boost participation. 2019. It is suggested that for every HK$1.00 invested 6. Starfield B, Shi L, Macinko J. Contribution of primary care into primary care, HK$8.40 is saved in costs on to health systems and health. Milbank Q 2005;83:457-502. acute care.2 Primary care reform, starting with 7. Gulliford M, Naithani S, Morgan M. What is ‘continuity of improvements in continuity of care, is in the city’s care’? J Health Serv Res Policy 2006;11:248-50. best interests. Such a reform would require strong 8. Reid R, Haggerty J, McKendry R. Defusing the confusion: stewardship that understands the complex needs concepts and measures of continuity of health care. of today’s patients, promotes patient-provider co- Ottawa: Canadian Health Services Research Foundation; 2002. production of health in an integrated people-centred 9. Health Care Voucher. Hong Kong SAR Government. system, and acknowledges the interdependence 17 Background of Elderly Health Care Voucher Scheme. of systemic elements in effective interventions. 2019. Available from: https://www.hcv.gov.hk/eng/pub_ Ultimately, this will allow Hong Kong to further background.htm. Accessed 15 Feb 2019. improve upon its current promising solutions, 10. Food and Health Bureau, Department of Health, Hong making it better equipped to address population Kong SAR Government. Interim review of Elderly Health health needs. Care Voucher Pilot Scheme. 2011. Available from: https:// www.hcv.gov.hk/files/pdf/ehcv_interim_review_report_ Author contributions en.pdf. Accessed 15 Feb 2019. The author contributed to the concept or design of the study, 11. Yam CH, Liu S, Huang OH, Yeoh EK, Griffiths SM. Can acquisition of the data, analysis or interpretation of the vouchers make a difference to the use of private primary data, drafting of the manuscript, and critical revision of the care services by older people? Experience from the manuscript for important intellectual content. The author had healthcare reform programme in Hong Kong. BMC Health full access to the data, contributed to the study, approved the Serv Res 2011;11:255. final version for publication, and takes responsibility for its 12. News.gov.hk, Hong Kong SAR Government. Health accuracy and integrity. voucher up for review. 2019. Available from: https://www. news.gov.hk/eng/2019/01/20190110/20190110_123219_0 Conflicts of interest 08.html. Accessed 15 Feb 2019. 13. Primary Healthcare Office, Food and Health Bureau, The author has no conflicts of interest to disclose. Hong Kong SAR Government. Primary Healthcare Office. Available from: https://www.pco.gov.hk/english/ Funding/support initiatives/centre.html. Accessed 15 Feb 2019. This commentary received no specific grant from any funding 14. South China Morning Post. Prevention better than cure: agency in the public, commercial, or not-for-profit sectors. Kwun Tong Community Health Centre helping Hong Kong’s growing elderly population stay one step ahead of References chronic illness. 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