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LCQ7: Treatment and follow-up care for psychiatric patients
     Following is a question by the Hon Yung Hoi-yan and a written reply by the Secretary for Food and Health, Dr Ko Wing-man, in the Legislative Council today (June 14):


     The Hospital Authority (HA) launched the Case Management Programme in different districts of Hong Kong by phases in the 2010-2011 financial year to provide community support services for patients with severe mental illness (SMI), and extended the Programme in the 2014-2015 financial year to cover all 18 districts across the territory.  As at March 31 last year, HA employed a total of 327 case managers to take care of over 15 400 patients with SMI (i.e. each case manager needed to take care of about 47 patients on average).  Some mental illness concern groups have pointed out that the wastage of case managers has been serious in recent years and the manpower shortage problem has become increasingly serious (for example, the current case manager-to-patient ratio in a certain hospital cluster is as high as 1:70).  Such concern groups have also pointed out that long-acting injectable antipsychotics (LAIAs) help reduce the relapse chance of patients (particularly those who do not take medication on time), and patients who receive LAIAs at the early stage of their illness may obtain better curative effect, which will benefit both patients and their families in the long run.  In this connection, will the Government inform this Council:

(1) whether it knows the number of case managers and the number of patients with SMI whom such case managers took care of, in the past three financial years, broken down by hospital cluster (set out in a table); 

(2) whether it knows the criteria currently adopted by HA for determining which patients with SMI should be taken care of by case managers, and the average time taken for following up each case at present; 

(3) whether it knows the number of patients with mental illness who are currently not being taken care of by case managers and whose conditions are stable but serious; whether HA has followed up and monitored the conditions of such patients through other channels; if HA has, of the details; if not, the reasons for that; 

(4) given that the relevant case manager-to-patient ratios in quite a number of advanced countries (e.g. Australia, the United States) range from about 1:20 to 1:25 at present, whether it knows if HA has assessed the number of additional case managers HA needs to recruit in order to be on par with those countries; if HA has assessed, of the outcome, including the number of additional case managers HA needs to recruit, the implementation timetable and the expenditure involved; whether HA will formulate short, medium and long-term improvement measures to reduce the workload of case managers; 
(5) whether it knows if HA will formulate a long-term strategy to enhance case management standards; if HA will, of the specific contents of and implementation timetable for the relevant long-term strategy; of the measures HA has in place to enhance the training for case managers; 

(6) whether it knows HA's estimated expenditure on drugs for patients with SMI in the current financial year and how such estimated expenditure compares with the actual expenditure in the last financial year;

(7) whether it knows, among the patients with mental illness in various public hospitals in the last financial year, the respective numbers and percentages of those who took (i) first-generation and (ii) second-generation oral antipsychotics, and those who received (iii) first-generation and (iv) second-generation LAIAs (set out in a table); and 

(8) whether it will allocate additional resources to HA so that more patients with mental illness will be provided with LAIAs, especially second-generation LAIAs which have less side effects; if so, of the details; if not, the reasons for that; whether it has plans to categorise LAIAs as first-line drugs in HA's Drug Formulary in the long run?

     The Hospital Authority (HA) adopts a multi-disciplinary approach in its provision of psychiatric specialist services.  The multi-disciplinary teams, comprising psychiatric doctors, psychiatric nurses, clinical psychologists and occupational therapists, provide patients, depending on their conditions and clinical needs, with the appropriate treatment and follow-up care, including in-patient, specialist out-patient, daytime rehabilitative training and community support services.  My reply to the various parts of the question is as follows: 

(1) to (5) The Community Psychiatric Services of HA provides a range of community psychiatric services, including Community Psychiatric Nursing Services, Case Management Programme, Intensive Care Teams and Mental Health Direct hotline, for needy patients according to their conditions, clinical needs and risk levels.

     The HA launched the Case Management Programme for patients with severe mental illness (SMI) under its Community Psychiatric Services by phases from 2010-11 to proactively provide intensive, continuous and personalised support for patients with SMI residing in the community.  Under the programme, case managers work closely with other service providers (particularly the Integrated Community Centres for Mental Wellness (ICCMWs) set up by the Social Welfare Department (SWD)) to provide community support for the target patients.  In 2014-15, the programme was extended to cover all 18 districts across the territory to benefit more patients.

     Table 1 at annex sets out the numbers of case managers and cases handled under HA's Case Management Programme in the past three years.

     At present, psychiatric doctors of HA decide whether to refer patients with mental illness to the Community Psychiatric Services for follow-up according to the patients' conditions and their clinical needs.  Patients may also be referred to Community Psychiatric Services through various channels such as ICCMWs funded by SWD or social workers.  Upon receiving the referred cases, the multi-disciplinary community psychiatric teams will provide patients with the appropriate community support services.

     Except for the few patients who decline the services (note 1), all others who are considered suitable will be arranged to receive community psychiatric follow-up services according to their conditions and clinical needs.

     As the number and duration of visits for each case under Community Psychiatric Services vary depending on the seriousness of illness, clinical needs and risk levels of the patient, HA does not maintain the average time taken for following up on each case.

     In April this year, the Review Committee on Mental Health published the Mental Health Review Report.  It recommends, among other things, that in order to further enhance the support for patients with SMI and lessen the burden on case managers, the HA should improve the ratio of case manager to patients with SMI.  The preliminary target was set at improving the ratio from the current 1:50 to around 1:40 in three to five years' time.  As such, HA will conduct a comprehensive review of the planning of Community Psychiatric Services and the manpower and training arrangements of case managers within this financial year.

(6) to (8) Over the years, HA has made every effort to increase the use of new generation psychiatric drugs which have proven effectiveness with fewer side effects, including antipsychotic drugs, antidepressant drugs, drugs for dementia and attention deficit/hyperactivity disorder.  Taking the patients' wish into account, psychiatrists will provide necessary drug treatment for patients as appropriate, having regard to their clinical needs and in accordance with the clinical treatment protocol.  The number of patients prescribed with the new generation antipsychotic drugs and ampoules (note 2) at public hospitals has increased from about 39 200 in the 2010-11 financial year to 82 300 in the 2016-17 financial year, representing an increase of almost 110 per cent.

     In the 2014-15 financial year, HA repositioned the new generation oral antipsychotic drugs (save for Clozapine due to its more complicated side effects) from the special drug category to the general drug category in its Drug Formulary so that all these drugs could be prescribed as first-line drugs.

     The new generation long-acting antipsychotic ampoule have already been incorporated into the special drug category of HA's Drug Formulary.  Psychiatrists will provide necessary drug treatment for patients as appropriate, having regard to their clinical needs and in accordance with the clinical treatment protocol.

     Table 2 at annex sets out the respective number and percentage of psychiatric patients of HA who were prescribed traditional or new generation oral antipsychotic drugs and traditional or new generation long-acting antipsychotic ampoules in the 2016-17 financial year.

     The HA has put into place an established mechanism under which experts examine and review regularly the treatment options and drugs for patients with adjustments made as appropriate, taking into account factors like scientific evidences, clinical risks and treatment efficacy, technological advancement and views of patient groups, etc.  The HA will continue to closely monitor the latest development of the clinical and scientific evidences of new psychiatric drugs.  It will continue to review and introduce new drugs, and formulate guidelines for clinical use of such drugs in accordance with the established mechanism having regard to the principle of optimising the use of public resources and providing the most appropriate drug treatment for needy patients.

Note 1: If a patient is a conditionally discharged patient under section 42B of the Mental Health Ordinance (Cap. 136), the medical superintendent may require the patient to receive community psychiatric services or otherwise may recall the patient to the mental hospital.

Note 2: Including long-acting and short-acting ampoules.
Ends/Wednesday, June 14, 2017
Issued at HKT 15:40
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