Speech by SHW (English only)

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Following is the speech by the Secretary for Health & Welfare, Dr E K Yeoh, at the First National Disease Management Conference co-organised by the National HealthCare Group, the Disease Management Association of America and the Ministry of Health, Singapore, in Singapore today (May 25):

Integrated Health Care Delivery - Infrastructure for Disease Management and Health Promotion

It is my great honour to be invited to participate in the First Disease Management Conference. Over the years, the Hong Kong Special Administrative Region of China and Singapore have been actively and constantly making exchanges of experience and views at different levels and on different areas of mutual interest. This Conference is indeed another very important occasion for us to share with you our experience in health care of Hong Kong. I am sure that all of us will greatly benefit from the excellent presentation of the most distinguished speakers in the coming two days. In this first session of the Conference, as a start, I am going to speak on how Hong Kong works towards an integrated health care delivery in the last decade and the challenges ahead of us. I believe that integrated health care delivery serves to provide solid ground for Disease Management to build on. Without such infrastructure, it is very difficult to realise the approach integral to disease management models, in which the multi-disciplinary, continuum-based, cross-system and outcome-focused components are indispensable.

Introduction of Hong Kong and its health care system

To start with I would like to make a brief introduction of Hong Kong. I guess many of you have been to Hong Kong and I notice that some of you were actually there last week attending the International Hospital Federation Congress 2001. Hong Kong is indeed not far away from here; the size of Hong Kong is about 1,000 square kilometers and our population is approaching seven million now.

As for health care, we have a dual system in which services are provided by both the public and private health care sectors. For primary care, 88 per cent of visits are in the private sectors. However, 94 per cent of the hospital services rendered to the local population are provided by the public sector. The Health and Welfare Bureau is the Government bureau responsible for health care policy in Hong Kong and it has two executive arms, one of which is the Department of Health. Another is the Hospital Authority, a statutory non-government body managing all the forty-four public hospitals in Hong Kong.

After this brief introduction, I shall move into the body of my talk. With reference to the different stages of the journey of building up the infrastructure for integrated health care delivery of Hong Kong, I shall follow the sequence of conceiving, constructing, consolidating and consummating the infrastructure, followed by my conclusion.

Conceiving the Infrastructure for integrated health care delivery.

We start with the question as to why we need a reform of the public hospital services in Hong Kong a decade ago. What was the impetus for us to conceive our "big-bang" change to establish the new Hospital Authority in late 1980s?

Back to the 1980s, our development in areas of economy, trade, commerce and industry had reached or out-performed the standards of many developed countries. However, the delivery of our public hospital services was lagging behind, not so much in the quality of medical care, but in hospital management and mode of service delivery. I shall very briefly summarise the significant problems in the public hospital services and why the environment at that time was not conducive to the development of integrated health care delivery.

First of all, I shall brief you on the organization of public hospitals in the 1980s. The hospitals at that time were organized in a three-tier system:

* The first tier was formed by regional hospitals. These were the major acute hospitals which were equipped to provide the treatment of patients requiring the highest level of specialist care. Some of their highly specialized services also served the entire territory.

* The second tier was constituted of district hospitals. These hospitals played a dual role. Besides providing "basic" hospital services in the region, these hospitals received transferred-in patients from the regional hospitals who had recovered from their acute phases and were in the convalescent period of illness.

* The last comprised infirmaries, which provided long term care for patients with chronic disabilities and illness requiring constant nursing care under some medical supervision

So what are the problems of such system? There were two major problems with such three-tier hospital system:

* Firstly, the system was disorganized and poorly coordinated. Some of the regional hospitals were being supported by up to five to six district hospitals distributed widely in the territory. At the same time, a number of district hospitals received convalescent patients from as many as three regional hospitals. Administration and coordination was far from satisfactory.

* Secondly, the standards were highly variable in district hospitals and infirmaries. Many of the clinical units in these hospitals where patients were transferred for convalescence were staffed by relatively few nurses and equipped with inadequate supporting facilities and sometimes no resident doctors. Knowledge and skills in rehabilitation were highly variable and staff morale in the district hospitals and infirmaries was low.

Apart from the way in which those hospitals were organized, there were some other problems. At that time, many of Hong Kong's major hospitals were amongst the largest in the world, with over 1000 beds each. Decisions were made centrally rather than at the individual hospital. Such a system led to inefficiency, unresponsiveness and low staff morale. The management system was unable to help hospitals keep abreast of worldwide trends and developments, particularly in hospital management practices.

Secondly, there was little cross-functional co-ordination in hospitals. Professionals of various disciplines contributed to the delivery of service following different objectives, resulting in gaps and duplication of services. Lines of accountability were unclear. Responsibilities in clinical care and resource management were separated. Clinical decisions were often made without full consideration of cost-benefits or the financial implications of resources used.

Thirdly, service development was professionally led. There was virtually no community involvement in the public hospital system. Public needs were not fully addressed and the services provided were not patient-orientated.

Fourthly, the public hospitals and medical institutions were managed by 16 independent providers. Some of the public hospitals were directly managed by the government while others were under separate non-governmental governing bodies with differing resource allocation systems and terms of employment of staff. This led to problems of co-ordination in service delivery, planning and development, as well as an inefficient and ineffective use of resources.

These problems resulted in the delivery of public hospital services that were far from satisfactory. The major government hospitals, in particular, continued to be under great pressure, manifested by overcrowding and long queues for treatment. This eventually led to the government's decision to review Hong Kong's medical services.

After thorough consultations, the Hospital Authority was set up in December 1990 with the objectives of improving the efficiency and effectiveness of hospital services through the introduction of a new corporate culture and scientific management.

In short, the establishment of the Hospital Authority manages to achieve four outcomes, which were:

* to increase flexibility of management;

* to improve quality of services;

* to increase community participation; and

* to increase accountability to the public.

To achieve such outcomes, many tools were adopted, the discussion of which is to be presented in the next section. This is about how to construct an infrastructure of integrated health care delivery.

Constructing the Infrastructure for integrated health care delivery

The change to establish the Hospital Authority can be said to be revolutionary but we take each step to improve in a planned and cautious manner. As the organization took over the management of the then 38 hospitals from the 16 provider bodies, we started to develop a set of guiding framework. We set out our mission to encapsulate the organisation's societal purpose, our vision to create our focus and our philosophies to fuel our driving force. Today, we may not be able to go through all of them but those related to today's topic will be covered here.

The pursuit of an integrated health care delivery was enshrined in our Corporate Vision developed in 1994:

"The Hospital Authority will collaborate with other health are providers and carers in the community to create a seamless healthcare environment which will maximize healthcare benefits and meet community expectations."

As you can see here, "seamless healthcare environment" is the key word in our Corporate vision.

Towards achieving its Mission and Vision, the HA formulated five strategic directions in 1994, which since served as the backbone framework for annual planning and service development in the organization:

* To create a Seamless Healthcare System;

* To develop Outcome Focused Healthcare;

* To involve Community as Partners in Health;

* To cultivate Organizational Transformation and Effectiveness; and

* To promote Corporate Infrastructure Development and Innovation.

So what are the initiatives for ensuring the creation of seamless health care system? I would think that clustering of hospitals was only one of them. I shall categorise these initiatives as follows:

1. Inter-disciplinary

* In order to address inter-disciplinary seams, we set up about 200 Clinical Management Teams, in which professionals from different disciplines can be organized together to contribute to clinical care is a well coordinated manner.

2. Inter-hospital

* For the inter-hospital potential seams, clustering of hospitals is a very important initiative.

* We have also set up Central Coordinating Committees at the Head Offices for various specialties so as to better coordinate the services offered by each specialty in a territory-wide manner. Clinical Practice Guidelines were also devised by these committees for dissemination and application.

* Moreover, we have invested on our Information Technology systems. We have more than a dozen systems developed in phases over the past years. Among them, the Clinical Management System allows an efficient transfer of patient record across the inter-hospital boundaries.

* We also had our own specialty costing system. The costing figures for each episode of care, be they inpatient stay or outpatients visits, were calculated to serve as a benchmark for inter-hospital comparison within and beyond the same cluster.

* Furthermore, having made reference to overseas experience in the usage of Diagnostic Related Groups, we also developed our own case-mix system and we called that Patient Related Groups. We have as yet 33 established Patient-Related Groups, and other groups include common conditions such as fracture neck of femor, Chronic Obstructive Pulmonary Disease etc. Standardised protocols were developed for these Patient Related Groups and the data collection for outcome evaluation of treatments were conducted electronically.

3. Inter-providers

* To address inter-provider issues, we are aware of the possible barriers limiting the ease for patients to choose among public providers and private providers. These are informational barriers, professional barriers and price barriers. We have piloted some shared care programmes in the territory to address this. In these programs, we harness the input of general practitioners in the private sectors in offering continuing care for patients with stabilized common conditions such as Diabetes.

4. Inter-sectors

* The next is on inter-sectoral collaboration. In Hong Kong, we have a separate government department, the Social Welfare Department, which oversees the component of social care for persons with disabilities in community settings. Long term care in Hong Kong is predominantly provided via various publicly funded non-government organizations. Broadly speaking, there are residential and non-residential services. Residential services span facilities specially designed for older persons, persons with learning disabilities and persons with mental illness. Non-residential services are provided in form of day centers, home-help services or sheltered workshops. Effective interface of the two sectors is of paramount importance. We have set up various community teams offering outreach geriatric, psychiatric and nursing service to join hand with the mentioned welfare sector services providers to serve people in the community. For example, whole continuum of psychiatric service is provided both by the Hospital Authority and various agencies in the welfare sector. Community teams then offer cross-sectoral services to patients under care of the welfare agencies.

We now elaborate on how we proceed with clustering of hospitals.

Clustering of hospitals

To start with, the objectives of hospital clustering were to prevent duplication, facilitate planning, enhance efficiency and improve quality. Our task was to provide a comprehensive scope of secondary acute hospital services within the cluster to cater for the need of all acute emergency patients, most of the affiliated specialist outpatient department patients and private sector referrals. In view of the problems related to the three-tier system, the concept of "hospital clustering" was introduced in 1992 to enhance the group relationship among hospitals in a geographical area, while taking into account the basic philosophy of the Hospital Authority of giving individual hospitals delegated management authority and responsibility. Each hospital in the group would have a different role.

With the initial phase of implementation of the hospital clustering concept, the three-tier system of regional hospitals, district hospitals and infirmaries was reorganized into acute and extended care hospitals delineated by the types of care required. One of the roles of district hospitals merged with regional hospital and the other with infirmaries.

This service re-organization provided for a better framework for defining hospital roles. It also facilitated continuity of care of patients throughout the two phases of illnesses, recognition of the resource required in the two types of hospitals and facilities and co-ordination of hospital operations.

In the first phase of implementing the cluster concept, the main target was to rationalize the transfer arrangements of the patients from the acute to the extended care.

In the second phase of clustering in 1994, the 38 hospitals and institutions were grouped into eight clusters for hospitals providing general medical services. This was based on the best match of the portfolio of existing hospitals having regard to the services provided, the roles delineated and geographical and demographic consideration and utilization patterns. Hospital services for the mentally ill and retarded were organized into two clusters as services for the mentally ill were historically planned and provided for on a territory-wide basis by only two major psychiatric hospitals.

The main advantages of hospital clustering are:-

(a) The comprehensive provision of care for each episode of illness in a single cluster

Grouping hospitals into a cluster would facilitate continuity of patient care and provide the framework for hospital role delineation and service planning.

(b) Service rationalization

With the formation of eight hospital clusters, rationalization of services also commenced. Services which were best provided in different types of institutions were relocated.

Collaboration with primary care providers in pre-hospital care and with carers in the community, patients and their families in post-hospital care had been developed and enhanced following the formation of the hospital clusters.

(d) Enhanced provision of community based services

Community based specialist care and out-reach specialist services in the community was reorganized in the context of the hospitals and ambulatory institutions within each cluster.

Hospital clustering provides one of the framework for the organization and provision of hospital services in a vertical dimension. The other framework for service provision is the horizontal dimension of "service networking".

The vertical form (dimension) refers to the health care provided at different time points in the different stages of the patient illness. This usually follows the sequence of acute care - extended care - community care. The primary objective of clustering is to incorporate this vertical form of hospital service organization and provision, by grouping hospitals to provider the different types of health care required at different stages in an episode of illness.

The horizontal form (dimension) refers to the organization provision of different specialty services within each of the acute, extended and community care episodes. Within each of the care episodes, services for individual patient are complex and provided by a number of clinical specialties, this is especially so for the acute care episode.

The horizontal form (dimension) operates across the physical boundaries of clusters and includes organization of specialties on a territory-wide basis (tertiary level services) which require advance technological support and special scarce expertise e.g. cardio-thoracic services - open heart surgery.

Due to the intensive requirements on expertise, facilities, when the number of patients requiring the treatment is relatively small, providing "tertiary services" in all clusters may not be desirable or justified. In that care, arrangement to ensure adequate and equitable access to these tertiary services in a few clusters could be sufficient. Three cardio-thoracic centers currently provide open-heart surgery for patients in all eight clusters. A horizontal structure or networking of services across cluster therefore can serve to avoid the duplication of specialized services, costs of the extra infrastructure and the under-utilization of expertise in any one particular cluster.

This horizontal form (dimension) of "service networking" has also facilitated sharing of different specialty services both within and between clusters. Examples of service networking include the networking of computerized Axial Tomography (CAT) and pathology services, which facilitated provision and sharing of these services. The benefit of service networking to patients can be illustrated by the movements of patients with heart attach in the two dimensions of service provision is shown in this slide.

Consolidating the Infrastructure for integrated health care delivery

We then proceed to discuss how the original form of clustering has been supported and consolidated by some critical success factors for integrated health care delivery. These are discussed under the headings system and people.

34. Firstly on systems. These can further be discussed under the sub-headings,

* For Hospital Management structure, the Hospital Authority has adopted the management paradigm incorporating a multitude of elements including decentralization, management-orientation and participatory management. A flat organizational structure is adopted and clear line of accountability is stipulated.

* For the planning system, a cluster-based planning approach is adopted with input from both the Head Office as well as Clinical Management Teams.

* As regards the financial system, the key element of this strand is the devolution of financial management to hospitals. Each hospital has its own finance department responsible for providing dedicated support for financial management, decision making on the utilisation of resources by our frontline unit and the clinical management teams. Head Office provides guidance and has developed financial policy and procedures, resource management tools, methodologies, and benchmark information to support hospitals in the financial management analysis of key cost drivers, the patterns of resource utilisation and in providing information to link resource inputs and outputs. The use of cost financial costing information is an important element in measuring the hospital's performance.

* For the Information Technology System, the IT function within HA is provided centrally to ensure economies of scale and to facilitate a uniform approach. The emphasis has always been on supporting the clinical processes. In fact, although we do not have the geographical spread of many places, our hospitals - and hence our information systems - are spread throughout the territory and our network today connects more than 50 institutions on Hong Kong Island, in Kowloon and the New Territories and also on the Outlying Islands. Nowadays, looking first of all at inpatient services, data for laboratory tests and radiology examinations are now available immediately at workstations on the ward. Computerised discharge summaries are produced, together with clear instructions for patients and, where necessary, referral letters to private doctors produced. Drug prescriptions are sent electronically to the pharmacy for patients being discharged. Such automation can significantly reduce the number. So, with our approach, the likelihood of medication errors is reduced, as are the waiting times for patients. It also eliminates a large part of the clerical effort involved. In outpatient departments, it has enabled us to develop a one-stop service for patients. Investigation results can be readily available during a consultation and a range of data can be seen on the screen instead of having to review hardcopy reports. This has enabled us to reduce the amount of paper flowing through our busy outpatient departments. Drug prescribing is automated. Our appointment system now calculates the drug prescription requirements of patients prior to the next scheduled appointment.

Then moving to "people", strong coordination within the cluster was achieved by designation of head office executive to take charge of coordination works and regular cluster management meetings were conducted. To bring about a change in mindset and to introduce policies and systems in support of a performance-based culture, we adopted certain strategies and some examples are brought to you here:

* Firstly, there was a clear direction on organisational performance - It translates the Annual Plan into departmental and individual staff objectives and work targets in order to ensure that that hospitals and individuals contribute towards the corporate priority areas. Promoting cluster coordination, as part and parcel of the corporate directions, was also one of the elements.

* Secondly, there existed an effective performance management system - With the introduction of a Staff Development Review system which focuses on the overall performance of staff and their future development.

* Thirdly, for introducing Appointment policies that foster performance and merit - An open appointment policy has been adopted

Consummating the Infrastructure for integrated health care delivery

Just now we have gone through what we did in the past. How about the future? How can we rise to the challenges ahead? How can we seek enhancement to make our system better? Last year, a comprehensive review of the whole health care system in Hong Kong was conducted by our Government. In order for the existing infrastructure to enable us to maintain the level of quality and efficiency which meets community expectation, we have set out 11 strategic directions and 33 initiatives for our future reform. Here we can discuss how our proposals may serves to sew the potential seams of health care in between different stages of our life course, different levels of care, different modes of delivery and different providers.

First of all, we notice that there is still room for improvement as far as our needs at different stages of our life course are concerned. We will hence enhance our health programs for specific target groups, namely, children, adolescence, women, men and older persons. The purpose is to ensure people in Hong Kong are offered lifelong holistic care from "cradle to grave".

Having introduced the improvements in hospital services we so wished a decade ago when we established the Hospital Authority, we have identified the challenge to better integrate the primary medical care and hospital services which are currently provided by different organizations. We are hence planning to transfer the existing General Out-patient Service operated by the Department of Health to the Hospital Authority. Such provision of whole continuum of medical care will help remove the potential gaps between the two levels of care. We are also exponentially increasing the numbers of trainees receiving structured Family Medicine over the years.

How about the barriers between providers in different sectors? We shall develop an electronic Health Information Infrastructure to capitalize on IT advances for sharing patient information among public and private providers. We also propose that the two sectors join hands in developing common clinical protocols for common usage.

Just like Singapore, people in Hong Kong are increasingly patronising Chinese Medicine, which is at present predominantly provided by the private sectors. We shall introduce Chinese Medicine into the public health care system, starting from outpatient service first. It is also our aim to support clinical research and facilitate the development of standards and models of interface between Chinese and Western Medicine.

As for funding arrangement, the government has agreed with the Hospital Authority in adopting a population-based funding mechanism, which is by itself a tool promoting a community-based care approach.

Conclusion

You would probably appreciate that today I have only made a very panoramic sketch of what we have done in the last decade in Hong Kong in pursuing integrated health care delivery. We understand that a constant evaluation of changes of the macro-environment is essential and timely actions to initiate evolution in response to such changes are indispensable. The challenges ahead are mammoth and the room for learning is ample and I hope that we can have valuable exchange of views in the next 10 minutes. Thank You.

End/Friday, May 25, 2001

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