HK health officials should pivot on pandemic to maximize healthcare efficiency

The fifth wave of COVID-19 continues to wreck the lives of many elderly people and the weak in Hong Kong. To head off macabre scenes that happened in Britain and France when the virus first hit Europe, the central government bestowed upon Hong Kong umpteen resources. The feat of completing the construction of several thousand beds in just a few weeks would not be possible without the Chinese mainland’s help. Recruiting unemployed workers, receiving vast amounts of timber and concrete from Shenzhen quickly and making sure busy hands are put to work efficiently is the formula to success. 

Red tape was cut to allow the construction of a temporary bridge that connects Shenzhen and Hong Kong for the efficient transshipment of building materials. By comparison, Hong Kong’s healthcare sector has not been coping as well when it comes to maximizing efficiency. Managing resources efficiently, both human and material, is crucial during times of crisis, not least because resource wastage has been plaguing Hong Kong’s healthcare system for decades.

No longer should the government see Hong Kong’s healthcare split up as private and public sectors … Private healthcare organizations have long leeched on government-subsidized programs, including colon cancer screening and influenza vaccination programs, to ensure a regular influx of dollars

Liang Wannian, head of the National Health Commission’s COVID Response Expert Team, aptly advised Hong Kong to concentrate elites in the best facilities to treat patients who are most ill. He is in fact proposing maximum efficiency. Indeed, this principle should underlie every policy the SAR government makes. What the local health officials still fail to grasp is that primary care is much more cost-efficient than specialist care by a yawning margin. It matters much that many who hold office in the Hospital Authority are themselves specialist doctors. And though many of them lack training in public health policy, human inertia dictates that they stick with old habits of seeing the healthcare system through a biased lens shaped by their specialty training. 

Resources are pumped into training more specialty doctors, and health officials may have felt comfortably reassured that they have answered people’s cries. An eight-hour queue at the emergency department; a one-year appointment for an orthopedic new case; a five-minute consultation for cancer patients; and above all, a feeling of defeat among healthcare workers — these problems only remained, if not becoming exacerbated.

Apportioning funds appears to be a viable solution to a simple problem, except neither is the solution beneficial nor the problem straightforward. The solution benefits ordinary citizens minimally because most money flows into specialist care. The bulk of pensioners are beset by chronic ailments that are best followed up by primary care physicians. That is because most such illnesses only deteriorate gradually over time, requiring stepwise titration of common medications per well-established international guidelines — well within the capabilities of a general practitioner. And specialists consult for a narrower spectrum of cases as they further subspecialize along their career, often leaving gaps in the care for patient diseases. 

Take diabetes, for instance. Cardiologists who excel at removing clots from the heart vessels may do little to empower patients to take on personalized healthy behavior — educating patients who are mentally capable and the carers of those who are not to synchronize the quantity of sugar intake with their circadian cycles, all the while titrating medication doses, is a tall order for specialists whose interests lie in their parochial realms — that is proved to significantly reduce organ damage of all sorts, translating into a massive reduction in healthcare costs per capita. Look to Liechtenstein, a small European country famous for conducting one of the first large-scale cardiovascular studies, where primary healthcare was bolstered to nip metabolic diseases in the bud, and health expenditures remained lower than peer countries.

The problem is hardly straightforward because of the complex interplay of existing stakeholders in the healthcare system who hold much sway and extract rent. The job nature of the Department of Health attracted a trove of healthcare workers who loathe fast-paced front-line work. Ossified structure enervates the passion of fledgling recruits. Managers, who were former juniors themselves, have promoted a culture of passivity instead of proactivity. Inclined to pare back the workload, employees are happy to work within the confines of outdated stipulations rather than revising guidelines to solve a real problem. And though a less-sluggish work culture permeates the Hospital Authority, some senior doctors may yet relish in low-touch toil that draws negligible threat of being sacked, at the same time leaving much work to their juniors. Hong Kong is not mired in this plight alone. Despite fellow Europeans inspired by Liechtenstein’s health programs, little has changed by feeble political will to break vested interests, much less to revamp their healthcare system.

Healthcare expenditures in Hong Kong have surged exponentially in the past few years, closely mimicking the trends of that in America and some parts of Europe. Most healthcare in Hong Kong is provided by the Hospital Authority. A weighty, centralized organization belying fragmented and asynchronous patient care bodes ill for the quality of healthcare in the long run. Repeated assaults by COVID-19 merely exposed long-standing cracks in our healthcare system while pushing its resilience to the brink of collapse. The Pareto solution is to strengthen primary healthcare, not halfheartedly, but by a stretch.

The Hospital Authority has gone headlong in the opposite direction. Recently announced plans to halt the operations of community outpatient clinics in the Kowloon West region are at best minimally helpful and at worst counterproductive. This is unduly implemented when the majority of infected patients require expedient access to primary care doctors who can prescribe pills and reassure them. Purchasing Merck’s new drug molnupiravir should make a stronger case for a switch of strategies. According to the US Food and Drug Administration, this novel pill is indicated for treatment of mild-to-moderate disease in adults testing positive for the SARS-CoV-2 virus, and who are at high risk of progression to severe COVID-19, including hospitalization or death. That means primary care physicians who have been serving local communities are well poised to prescribe the drug. And patients who suffer from mild-to-moderate disease should be educated to not attend emergency departments to start with.

However, health administrators are busy mulling ways to stem misuse of the drug. One of their plans is to set up prescription criteria that patients need to fulfill before receiving the drug. Indeed, that is most convenient for policymakers who feel uncomfortable working beyond their remit and liaising with other departments to improve the healthcare system altogether. But that is missing the big picture. Putting the onus on emergency care physicians to limit prescriptions to those who should seek care from primary care physicians is using an ambulance instead of a fence (harkening back to Dr. John Hurty’s satirical poem about inefficient healthcare systems), as it helps little to spare emergency services from being overused. These patients need isolation rather than hospital treatment, and they should remain in quarantine camps or residential flats until recovery.

Moreover, anecdotal accounts of test-positive citizens refusing to report to officials either because they find it minimally useful or they fear penalty on insurance claims abound. Therefore, health officials should deploy massive numbers of primary care physicians to work in isolation facilities and prescribe the drug for those who are indicated. For better efficiency, telemedicine can be implemented in presumably well-patrolled facilities that house patients en masse. All this provides an incentive for patients to obtain molnupiravir in isolation facilities and acts conveniently as a counterweight to both emergency hospital misuse and fear of registering their COVID-19 infection status.

Another blunder of local health officials is less conspicuous but no less detrimental to the integrity of the healthcare system, especially in a crisis when manpower is wanting. Indulging in the vast resources sent from the mainland without deft use of it is tantamount to a boiling frog. Lives will perish if manpower is not put to good use. Surgeons continue to idle amid the postponement of elective surgeries. Radiologists staunchly refuse to land on ground zero, citing their rusty clinical knowledge, a fundamental skill required for physicians to graduate from medical school. Some senior physicians crow against temporary reassignment of their jobs to emergency departments and infectious wards so they can stand firm in their positions to protect the lives of other citizens, which is code for keeping themselves at bay from the “dirty work” currently done by junior doctors. These obstacles are far from insurmountable. All the more reason for bold leadership to manage human resources efficiently.

Even more appalling to the physicians working on the front line is the shunting of some lucrative procedures and surgeries to private hospitals. Alleviating the workload of public doctors itself is welcomed. However, in the broader context of private hospitals refusing to see COVID-19-positive patients, it is reasonable for the healthcare workers to take issue. There is insufficient negative pressure room to isolate more than a few COVID-19 patients, says a representative of private hospitals. Citizens growl that it is hard to see how public hospitals have enough facilities. As Professor Gabriel Leung put it squarely, no system in the world is built to withstand such pressure. But though private physicians are aware of the global shortage of select facilities, most continue to divert patients back to public care. Desperate times call for desperate measures. No longer should the government see Hong Kong’s healthcare split up as private and public sectors. “We are in this together” entails as many medical workers soldiering on the front line as possible to defend the health of citizens. 

So far, the government has been reluctant to mandate private hospitals to share bed statistics and other hospital data with Hong Kong people, which underpins crisis planning. Private healthcare organizations have long leeched on government-subsidized programs, including colon cancer screening and influenza vaccination programs, to ensure a regular influx of dollars. Punitive measures such as restricting bad apples from bidding on lucrative contracts from the public healthcare system could incentivize them to serve the fiduciary responsibility just as healthcare providers are meant to.

Other cross-functional liaison issues benight well-intended policies. A citizen who lives with his child and wife had their test-positive domestic helper sent home by emergency doctors, thereby exposing the damning communication breakdown between the Department of Health and the Hospital Authority. A few residential care owners refused medical teams to jab elderly people on-site despite the recent implementation of mandatory vaccination programs by the Department of Health allegedly because they received no such notice from the government.

What more can go wrong? Plenty. And many people’s lives are at stake. Alas, if the health officials in power continue to treat the symptoms rather than the root cause, no amount of resources can save them and pitifully, us. While local citizens expect little forward-thinking from them to reimagine the healthcare system, they may hopefully cower under pressure from top-down to manage this crisis well. Yet it is because of, but not despite, the incompetence of senior health administrators that will leave central government officials in disenchantment. As soon as the crisis remains under control, it would be wise for the next in power to appoint a reformist who wields compelling political willpower to spearhead the health office, break corrupt traditions, and mend fragmented systems.

The author is a licensed medical doctor in Hong Kong and holds a master of public health degree from Johns Hopkins University.

The views do not necessarily reflect those of China Daily.