Following is the speech by the Secretary for Health and Welfare, Dr E K Yeoh, in the motion debate on "Accident and Emergency Services" in the Legislative Council today (Wednesday):
There has recently been quite a lot of debate about whether the Accident and Emergency service (A&E service) should be charged to reduce inappropriate use by patients with non-urgent medical conditions. While some agree that A&E charging could be a viable solution, others argue that the fundamental issue lies with the inadequacy of our primary health care system. Today's debate is particularly timely as we will soon release a consultation paper on the health care reform, which will also touch upon this issue. I am glad that I could have a chance to express the views of the Administration on this very important subject.
Heavy public reliance of A&E service
The key functions of A&E departments of public hospitals are to provide emergency life support and emergency care for critically ill or injured patients and to provide emergency management for massive casualties during occurrence of major accidents and disasters. However, we note that there has been increasing public reliance on A&E service which is evident by the increase of A&E attendance per 1,000 population from 226 in 1991 to 347 in 1999.
To ensure that patients requiring urgent medical attention are treated promptly at all times, the Hospital Authority has established a triage system in all A&E departments to prioritize patients for treatment according to their medical conditions. Patients are triaged into five categories - critical, emergency, urgent, semi-urgent and non-urgent. In the first six months of 1999-2000, semi-urgent and non-urgent cases comprised about 60% and 15% respectively of the total A&E attendance of about 1.6 million. In other words, only 25% of the patients treated by A&E departments actually require emergency services.
Measures implemented to cope with the high demand
In view of the ever-increasing demand for A&E service, HA has already introduced various measures to cope with the pressure on A&E departments, including staggering the shift hours for medical and nursing staff to better match the arrival patterns of patients at peak attendance hours; deploying additional medical staff at A&E departments to work on anticipated busy sessions; informing "non-urgent" patients of their expected waiting time so that they may consider other alternative treatment options.
General Outpatient service provided by the Department of Health
At present, the Department of Health operates 64 general outpatient clinics (GOPCs), as well as 22 evening and 11 public holiday GOPCs in the territory. In the past two years, the Department has already increased the number of evening and public holiday clinics, and provided morning and afternoon sessions during public holidays. In 1999, the average utilization rates were 92% for day clinics, 82% for evening clinics and 83% for Sunday and public holiday clinics respectively. The Department still has capacity to meet the needs of more patients.
Service provided by private medical practitioners and private hospitals
In addition to medical services provided by the public sector, all twelve private hospitals and about 3,000 private practitioners also provide outpatient services. All private hospitals provide 24-hour out-patient clinic service. Most private practitioners work beyond 5 pm into the evening.
A survey conducted by HA in 1998 showed that A&E departments recorded the lowest attendance at 2am to 7am, and the highest attendance at 9am to noon, 1pm to 4pm and 8pm to 11pm. It was also found that the percentage of semi-urgent or non-urgent cases remained quite constant at about 70% in different hours of the day. It was worth noted that DH's GOPCs and private clinics also provide outpatient service during the A&E peak hours in the morning and the afternoon sessions. It shows that patients who seek treatment at A&E departments are not without alternatives. Therefore, we do not think by increasing the service quota or extending operating hours of DH's GOPCs can effectively resolve the overcrowding problem of A&E departments.
However, it is undeniable that A&E service offers some attractions. A&E departments provide around-the-clock service, which is easily accessible to the public. A&E departments also provide a whole range of medical services, including different diagnostic tests and procedures, which are provided at no charge. In addition, patients sometimes have difficulties in determining the severity and urgency of their illnesses, hence, they fail to judge accurately which type of medical service that they should seek. I believe we need to tackle the problem from different areas, including to review the current system of health care delivery, the development of primary health care service, A&E charging etc. These have just been covered by several Members.
Proposal to set up out-patient clinics next to A&E departments
Some Members have raised the proposal of setting up 24-hour outpatient clinics next to A&E departments. HA is now discussing with the Hong Kong Medical Association a pilot scheme of setting up private walk-in clinics next to two A&E departments for a period of six months starting in mid-2000. A group of private practitioners will be recruited to provide out-patient service at market rate. Patients who are triaged to be semi-urgent and non-urgent would be informed of the estimated waiting time for treatment and advised of the alternative choice of service provision at clinics next to A&E departments. Given the relatively long waiting time for patients triaged as semi-urgent and non-urgent, which is targeted at less than 90 and 180 minutes respectively, patients might choose to go to the clinics next to A&E departments for prompt medical attention.
Clinics in public housing estates
Regarding the allocation and operation system of clinics in public housing estates, the Housing Authority conducted a review of this letting policy in 1999. Having considered the views from various bodies and the general public, the Housing Authority decided that, with effect from this year, it will change the old balloting system for members of the Estate Doctors Association only, but to adopt the open tendering system to enhance fair competition and transparency.
Under the new system, the new tenancy agreement also requires the tenant to open the clinics for business for a minimum of six hours per day except on Saturdays, Sundays and public holidays. The Housing Authority reserves the right to introduce additional clinics at any time and will do so if there is evidence of monopoly or if it is considered to be in the interests of the local residents. Regarding the operating hours on Saturdays, Sundays and public holidays, I will suggest to private practitioners and the Housing Authority to consider implementing measures in some estate clinics to provide service during these days.
Service provided by private medical practitioners
Some Members have suggested that Government should promote the setting up of comprehensive primary care services in private housing estates, in order to provide the public with more choices of services. In the current market, the supply of medical services by the private sector is driven by demand. We consider that there are not enough justifications for us to interfere the market operation. However, we agree that our primary health care system does have room for improvement.
Improving primary health care service
We recognize that apart from reducing patients' reliance on hospital services and relieving the pressure of total health care cost escalation, further strengthening of primary medical care can bring added benefits to the health of the community as a whole. Primary medical care emphasizes on the provision of preventive care in a community setting. As a result, early detection and disease treatment become possible in minimizing the health and financial risks imposed on patients.
We consider that through the strengthening of family medicine for doctors at the primary care level, they could offer more comprehensive care to patients, improve treatment efficacy and enhance the continuity of care. We understand that relevant professional bodies are examining the development and adoption of certain continuing education program to enhance the application of family medicine. We are also actively considering using public hospitals under the Hospital Authority as a training ground to further develop Family Medicine, and have more specialists trained in this discipline. The Hospital Authority has started to recruit family medicine trainees to provide a comprehensive medical care in its integrated clinics.
Moreover, it is also important to improve the collaboration between various sectors within the local community. For instance, a better coordination on referral and shared care between primary care providers and specialists, and a closer collaboration between public and private sectors. These improvements provide more timely and efficient care for members of the public, particularly for chronic patients. This would in turn alleviate demands for A&E services through a decrease in morbidity rate.
In our current review of the health care system, we have fully considered issues in this aspect and have been contemplating concrete reform measures, with a view to improving the existing primary medical care services. We will set out our detailed reform proposals in the forthcoming consultation document, and consult the views of all sectors of the community.
Proposal to charge A&E patients
Finally, I would like to respond to the issue on whether we should introduce A&E charging. I understand that, under the current economic situation, any introduction of new fees and charges is going to be a sensitive subject. We believe that the issue of A&E charging could not be considered alone, but should be considered in the context of the financing of the whole health care system. Hence, the suggestion of introducing charging for A&E services as well as the review of fee levels of other public health care services will form part of the whole health care review exercise.
In considering the proposal of charging for A&E services, we need to have a clear understanding of the current situation in A&E departments, as well as the objectives of such proposal. Under the current triage system, all patients with genuine urgent conditions will not be deprived of timely and appropriate treatment, notwithstanding the overcrowding and long waiting time in A&E departments. However, statistics show that about 75% of patients visiting A&E departments are non-urgent cases; and this occurs even when there are alternative medical services available. We therefore believe that through the introduction of a suitable charging scheme, we can effectively affect patients' choice of different medical services and reduce inappropriate use of A&E services, thus alleviating the burden imposed on A&E departments. I must stress that the purpose of A&E charging is not to recover cost, nor to raise revenue.
When considering A&E charging, we have to take into account the principles and objectives underlying any charging policy. Should the policy aim at differentiating the relative priorities of different services, and affecting the patients' behaviour? Should the policy work towards better targeting the government subsidies at those areas in need? We should, of course, also bear in mind those who are lack of means. A safety net must continue to operate to provide protection for those needy and to ensure that any charging policy would not deprive patients with genuine needs of access to services required.
In today's motion debate on "A&E service", I wish to convey the message that every society needs to provide A&E service. Given that A&E departments provides a comprehensive range of services, A&E service, when compared to other services, might be more attractive to patients. Moreover, since the public cannot fully understand the severity of their illnesses, the inappropriate use of A&E service cannot be totally avoided. The question is how we can implement a set of measures to minimize this situation and to ensure cost effective use of taxpayers' resources. I hope that the measures that I mentioned above would be accepted by the public and Members.
Thank you, Madam President.
End/Wednesday, March 1, 2000