Speech on the “Motion of Thanks” (Translation) President, there are 10 chapters in the Policy Address this year and if the chapters on "Introduction" and "Conclusion" are excluded, there are only eight. The fact that Chapter VII is devoted to healthcare indicates that it is an important area. However, there are only seven paragraphs in that chapter. The contents are nothing more than the initiatives which have been introduced, such as the proposed hospital in the Kai Tak Development; minor works projects for which the funding proposal of $13 billion has been approved by the Finance Committee; the Health Protection Scheme which has been studied for years; mental health services, as well as proposals for which no specific details have been given. It seems that the only bright spot is the increase in the value of elderly health care vouchers to $2,000 which is mentioned in the Chapter on "Poverty Alleviation, Care for the Elderly and Support for the Disadvantaged".
As we can see, healthcare is not important enough to get more attention from the Chief Executive. The fundamental reason is that healthcare is usually not the main focus in any policy address. Chief Secretary for Administration, she has left the Chamber now. It does not matter. I wish she could hear what I am going to say because I will be speaking on population policy.
Population policy is a hot topic which involves many controversial issues such as the daily quota of the One-Way Permit Scheme, population ageing, manpower shortage and importation of labour. In discussing the topic of population policy, we have to talk about the issue of healthcare manpower in public hospitals. Many people will take this opportunity to advocate the importation of overseas graduates. I had communicated with some public officers earlier, at first, I was not very worried, but later I found that the Chief Secretary ― she has left the Chamber but that is alright ― had made some comments on the importation of overseas doctors at the Forum on Population Policy held by the Hong Kong Coalition of Professional Services on 6 January. She said that only 112 overseas doctors met the eligibility requirements to practise in Hong Kong over the past few years. As many job vacancies were available in the Hospital Authority (HA), she queried why the medical profession would not adopt a more open and lenient approach in allowing medical graduates in Europe or the United States to come to Hong Kong to practice? Strangely, the Chief Secretary also pointed out in her speech that under CEPA, opportunities were provided for people of Hong Kong to practise in the Mainland. So, is our manpower adequate or inadequate? How come overseas doctors would come to practise in Hong Kong while Hong Kong doctors would go to practise in the Mainland?
I thought I had clearly explained the problems of public healthcare services in Hong Kong in the past, but now I do not mind taking the trouble to discuss them again on this occasion. First of all, regarding the importation of overseas medical graduates, I think we should adopt similar arrangements as that adopted by other industries and trades. If there is really a manpower shortage problem and sufficient manpower cannot be recruited by offering a reasonable salary in the market, then importation of labour is required. However, consideration should be based on data and logic, and not on what people say. I have heard the remark of "many people said" made by the Chief Secretary. That is actually a terrible thing to say. Does the Chief Secretary mean that a lie repeated a thousand times will become the truth?
Speaking of data, I can put forward my set of data while others can put forward theirs, and I have noticed they have. While we have to take data into account, we have to consider how the data should be analysed and chosen as well.
Let me give an example. Former Member of the Executive Council Mr Franklin LAM said that according to his calculations, 40% of our doctors would retire in the next 20 years. As there would be a huge demand for doctors, we should substantially increase the supply of doctors. May I ask Members what they think of the statement that 40% of our doctors will retire in the next 20 years?
For those who have a clear mind such as the President who studied Mathematics, they would be able to understand better. Let us assume that a doctor works from the age of 25 to 65 and has a working life of 40 years. If the age distribution of doctors is even, 2.5% of all doctors will retire each year. According to such a normal distribution, 50% of all doctors will retire in 20 years and the said 40% will be an underestimation. Therefore, the anticipated percentage of retirees is not a problem. It is only a natural phenomenon in all occupations. If 40% of doctors are really retiring, the percentage of younger doctors will constitute 60%. Therefore, after 20 years, even without implementing any initiative, the number of doctors will increase by 50% due to natural growth. Therefore, what Mr LAM said is just nonsense. In addition, some people use the doctor to population ratio to assess whether the number of doctors in Hong Kong is adequate. For example, the ratio in the United States is 1:400 while that in Hong Kong is about 1:700. However, I would point out that the circumstances in every country vary. The population is generally more scattered in overseas countries and they would need more doctors because some people live in rather remote areas. Even in the not so remote towns which have a small population, they also need a certain number of doctors because the population distribution is scattered. Therefore, there will be a greater number of doctors.
Furthermore, the ratio of resources allocated for public healthcare to GDP in many European countries and the United States is twice that of Hong Kong. If the Hong Kong Government can promise to increase the percentage of funding in public healthcare from the current 3% to 5% or 6%, there would be no problem in increasing the number of doctors by 50% because the Government has promised to employ them.
Let me give an example which relates to dentists. As we are very dissatisfied with the public dental services provided in Hong Kong, my suggestion is that the Hong Kong Government should set a target in increasing the ratio of funding allocated for public dental services to that of public healthcare services. I think the current funding allocated for public dental services is less than $1 billion. Suppose the funding for the general public healthcare services is $50 billion, the funding allocated for public dental services represents only about 2%. That is a very small percentage when compared to the figures in Europe and the United States. The ratio of funding allocated for public dental services to that of public healthcare services can be increased to 4%. In response to this suggestion, the Government will probably say that it is useless to increase funding because the problem lies with manpower shortage. However, as an adage goes, "Before the marching of the armed forces, food and fodder should go first". What does it mean? If funding is increased, the situation will not worsen even though dentists have not been recruited, will it? It is preferable to increase the funding first so that we can start training the talents and utilize them in due course. However, if the approach is reversed and "The armed forces start marching before food and fodder arrive", it will be a disaster because people will be starved to death. Therefore, "Before the marching of the armed forces, food and fodder should go first". The Government should first commit to increasing the funding. The number of dentists can be increased gradually as the need arises and manpower shortage will be resolved eventually. The argument applies to the situation of doctors. If the Government promises to increase the ratio of public healthcare funding to 5% or 6% of the GDP, it is alright to increase the number of doctors. My biggest worry is that soon after the number of doctors has been increased ― the Financial Secretary has warned us that the fiscal reserve will be depleted one day and tax has to be increased then. When a large number of medical students will graduate in eight or nine years, we may no longer have any money to employ them. As I have said repeatedly, the shortage of doctors may be attributed to the management problem of the HA. Why do people think that there is a shortage of doctors? The reason is that patients have to wait a long time to receive medical services provided by the HA. However, if we take a closer look, the long waiting time of patients does not exist in each hospital cluster. Take orthopaedics as an example; the Secretary is an orthopaedic surgeon. The waiting time for obtaining orthopaedic services in the Kowloon East Cluster is 107 weeks, but it is only 15 weeks in the Hong Kong West Cluster. The length of the former is six or seven times the latter. Why is there such a big difference? The reason is that Hong Kong West has more funding than Kowloon East, it has $8 million-plus per 1 000 people while Kowloon East only has $4 million per 1 000 people. The staffing establishment of Hong Kong West is also doubled that of Kowloon East.
Although the Government has provided additional funding to the HA over the years, Kowloon East only takes up 10% in terms of distribution while for Hong Kong West … I forget the percentage, but it is far higher and almost twice as much as Kowloon East. No matter how much the Financial Secretary has increased the funding provision, the HA still has not changed the ratio of distribution, and the problem of manpower shortage has still existed. In fact, there was a substantial increase in the number of staff, but the additional staff members have not been deployed to departments with manpower shortage problem. Therefore, the problem of manpower shortage will persist forever and the waiting time will remain long. To resolve the problems of long waiting time and manpower shortage, reference can be drawn from the wisdom of 3 000 years ago in that "Inequality is worse than deficiency". Therefore, the first step that should be taken is to allocate resources equitably.
Apart from allocation of resources, another crucial factor is to establish a mechanism of "more work, more pay". Over the last month or so, many people suffered from influenza and they went to the accident and emergency (A&E) departments to seek treatment. As a result, the waiting time at A&E departments has been lengthened and non-urgent patients have to wait six to seven hours to receive medical consultation. How should the problem be resolved? The Government's proposals of importing labour and increasing the number of medial graduates can only solve the problem after a long time. Instead, I now put forward a proposal. At present, medical personnel working in the A&E departments work 44 hours a week. If overtime pay is offered to them for working four more hours, manpower will be increased by 10% and non-urgent patients can be attended to without having to wait six to seven hours. Why do the authorities not take any action? Actually, actions have been taken, but are the measure taken by the HA appropriate? The HA has employed part-time doctors at a salary rate of only 70% of full-time doctors, but they have to work 44 hours a week (including on-call hours) just like full-time doctors of A&E departments. Since these part-time doctors receive a salary at 70% of the normal rate, it goes against the laws of the market. How then can the HA recruit the staff required?
After all, why has the HA taken such measure? My conspiracy theory is: The HA does not have any incentive to reduce the waiting time. Since the current waiting time is long, Members will strive to convince the Financial Secretary to give additional resources, funding and manpower to the HA. If the waiting time is long, it will be justified to demand for additional resources. If the problem of waiting time is resolved, no additional resources will be given. Why will the HA have any incentive to reduce the waiting time? Furthermore, the HA often claims that it has manpower shortage problem. If this reason is accepted by everyone, it indicates that the HA has made no mistakes and neither has the Secretary. Even if there are any mistakes, they were committed by the Government of the last term because the problem of manpower shortage cannot be resolved immediately. In that case, the Secretary and the HA do not have to do anything.
Therefore, if Members truly hope that the HA can improve the healthcare services, I would ask them not to talk about manpower shortage for the time being. Instead, they can help by asking the HA to employ more part-time doctors at a reasonable hourly rate comparable to that of full-time doctors.
The two points mentioned by Mr Albert HO just now are the shortage of senior doctors on night shifts and the development of primary healthcare. These two points are actually related to establishing a mechanism in which a reasonable hourly rate is offered and the principle of "more work, more pay" is followed. What are the reasons for that? If senior doctors are asked to return to the hospital at night to handle certain emergency cases or serious cases ― perhaps I should not use serious cases as examples as senior doctors will not be so mean and they surely return to the hospital. However, for cases which are not very complicated, perhaps senior doctors may not return to the hospital as they will not get any additional pay. If a mechanism in which the principle of "more work, more pay" is established, I believe these doctors will be more willing to return to the hospital during unsocial hours to teach the less experienced doctors how to handle emergency cases.
I have also discussed with friends in the business sector about the manpower arrangements to be made to meet the fluctuating demand for services with uncertain resources available. For example, during the current influenza pandemic when the utilization rate of the HA hospitals reaches 110%, what arrangement should be made to make the best use of resources? At present, the strategy employed by the HA is to employ more people. Let us consider, if more staff members are employed to meet the demand arising from a utilization rate of 110%, what arrangements should be made for these people when the utilization rate drops to 75% after the pandemic? Should they continue to get paid? If a business is faced with seasonal fluctuations in demand, it will adopt the flexible and direct approach of giving overtime pay to its staff members, or recruiting part-time or out-sourced workers. That will be a more flexible approach.
If the mechanism of "more work, more pay" has the many advantages which I have mentioned, why is the Government unwilling to introduce it? Two months ago, I expressed my views at the Congress of the Hong Kong Academy of Medicine. Dr Margaret CHAN FUNG Fu-chun was also present and she was one of the speakers. She said she objected to the approach of "more work, more pay" for doctors because if such an approach was adopted, doctors would work very hard, leading to an increase in the demand for services. In other words, unnecessary demand would be generated. Since she was the speaker on stage and I was a member of the audience, I could not speak then. But at that point, I considered that she was making conflicting statements. On the one hand, she said that the demand for services was great and there was a shortage in manpower. On the other hand, in response to my proposal of establishing a "more work, more pay" mechanism to enable doctors to do more work, she said that more demand would be created. Is the big demand for services the reason or the result? Furthermore, some people have pointed out that the Government does not want to establish a "more work, more pay" mechanism because some staff members are working overtime without payment at present. If such a mechanism is established, the Government will have to pay for the additional expenditures. Last year, I asked the Secretary whether the Government was prepared to pay. He said that if additional expenditures were incurred, the salaries of the incumbent staff members had to be reduced first. A "more work, more pay" mechanism can only be introduced after a reduction in the salaries of the incumbent staff members. That was what he said. After hearing that, I suggested the Secretary to calculate how much additional expenditure would be involved because we could not be sure whether the Chief Executive would be willing to pay. It seems to me that the Chief Executive had once asked how much money would be involved, so I suggested the Secretary to do the calculations first. At that time, I actually asked the Chief Executive of the HA to do the calculations. When he remained silent, the Secretary said this could not be done because in doing so, it would mean that the Government was willing to make a commitment. I considered it unreasonable for the Government to make such comment. I was only asking the Secretary to do the calculations and I did not request for a commitment. All I wanted to know was how much money would be involved and whether the Government could afford, but he was not even willing to do the calculations.
I have stated my points of argument and all the figures quoted are open to the public. Very often, after I have spoken to the reporters, they would remain silent. Reporters are good in critical thinking and they cannot find anything unreasonable in my argument. It was not that they could not understand what I said, because I was speaking slowly within the time frame of nearly 30 minutes.
For some unknown reasons, some people would begin to smear the medical sector when they cannot get what they want in a discussion based on figures and logical reasoning. I argue that calculations have to be done and if there are good reasons to import labour, we should follow the arrangements in the other sectors. When people cannot win over me in an argument, they resort to smearing. As I am a doctor too, they would label me as a protectionist indiscriminately. For example, they would say that as 85% of the members of the Medical Council of Hong Kong (MCHK) are doctors, they will put up strong resistance to any kind of reform. I have to stress that half of the members of the MCHK are actually appointed by the Government. The Government has considerable influence over the MCHK and members who are elected to the MCHK … Talking about elections, you know that with direct elections, even a very imposing person may not necessarily win out. Therefore, frankly speaking, it is hard for elected members of the MCHK to perform their functions and persuade the MCHK not to pay heed to the Government. The Government has a strong influence over the MCHK.
Some people say that although the HA is facing manpower shortage, it fails to recruit overseas doctors because of objections from doctors. This explanation is a bit misleading. It is true that the Hong Kong Medical Association objects to recruiting overseas doctors with limited registration to fill the vacancies arising from the so-called manpower shortage, such objections are ineffective. Once the HA receives an application and considers the applicant suitable, it will submit the application to the MCHK for approval. As far as I know, all applications submitted to the MCHK have been approved with only one exception. That has been the established practice for the last two years. According to the figures I have in hand, only 16 doctors have been employed by this approach. Given that there are 5 000-plus doctors in the HA, the approach only has a limited effect. As such, the approach is not feasible.
In addition, the Chief Secretary said earlier that there are 310 vacancies of doctors in the HA. However, after browsing through the webpage of the HA and the advertisements, I cannot find the advertisements of the 310 vacancies. The HA is now recruiting about 10 people and the vacancies are not found in the clusters of the New Territories East Cluster and the Kowloon East Cluster which, according to our understanding, have the biggest problem of manpower shortage. Given such poor management on the part of the HA, I think it has not fulfilled the conditions for importing labour.
Some people may ask what harm will there be to have a great number of doctors? Are there any problems with it? It does no harm to have an excessive supply of doctors. The truth is, given that training resources are limited, if there are too many doctors, the standard will deteriorate. If we insist on having 420 medical graduates each year, we will see very young doctors with limited experience in the public hospitals all the time. Even in the private sector, if there are too many doctors … I for one will be twiddling my thumbs. The time for real work will be greatly reduced, and so is the chance for handling serious cases. While I will become more unfamiliar with my work, patients have to share higher operating costs of the clinics. If there are many service providers in the private sector who do not have enough business, patients will have to pay a larger share of the operating costs.
Furthermore, if there are too many doctors, a considerable amount of provider-led demand, that is, unnecessary service, will be created. According to overseas experience and backed by statistics, the greater the number of doctors in a place, the higher the overall medical expenditure. A few years ago, the Panel on Health Services of the Legislative Council went to Japan for a duty visit. One of the findings of the visit was that while Japan had a serious problem of population ageing, it had limited the number of medical graduates. In this Policy Address, there is an example of provider-led demand, namely colorectal cancer screening, that is, conducting fecal occult blood tests. Members may query why I say that may be a provider-led demand. It is true that overseas experience shows that colorectal cancer screening can reduce the morbidity rate and death rate of colorectal cancer. However, the figures do not show that colorectal cancer screening can reduce the overall death rate. In other words, if people do not die of colorectal cancer, they may die of many other illnesses.
Is colorectal cancer screening useful then? I have to declare interests first. I am a colorectal surgeon. With screening, the rate of death caused by colorectal cancer will be reduced by 15%, but people who have been screened may suffer from other problems. If we are to conduct such screening, there must be sufficient resources in our public health system. Since screening is population based and will be conducted for all, it will be conducted by public healthcare institutions. Hence, resources in the public health system must be sufficient. However, what is the current situation in Hong Kong? A patient suffering from hematochezia has to wait six months to get a colonoscopy examination. What are we going to do with patients who are found to be suffering from hematochezia after screening but have no symptoms otherwise? They may have fecal occult blood after eating steaks. The cost for conducting a colonoscopy examination in a public hospital is $10,000-plus which is not cheap. How are we going to make the arrangements in future?
In the remaining three minutes, I would like to talk about the issue of establishing a Chinese medicine hospital again. My friends in the Chinese medicine sector hope that such a hospital will be publicly run and will provide Chinese medical services only. Why? The reason is that they are afraid of doctors of Western medicine. Why would they like the hospital to be run publicly? The reason is that a Chinese medicine hospital will not be able to make any profit and it will probably incur losses. The Government will certainly not want to commit in anything which will incur losses. So, what idea does it have in mind? It can establish a hospital which provides both Chinese and Western medical services. Will it be "crying up wine but selling vinegar" then? Just like the Chinese medicine hospitals in the Mainland, more than 80% provide Western medical services and only about 10% provide Chinese medical services. The Government has also indicated that it would let a non-profit-making body operate the hospital. But, if the Chinese medicine hospital is to provide Western medical services, why does the Government have to let a non-profit-making body operate it? Running a hospital of Western medicine is a profitable business. The Government has let non-profit-making bodies run hospitals in the past and each and every one of them makes profits. I may as well name those hospitals. They include the Hong Kong Baptist Hospital and St Teresa's Hospital. Although the boards of directors of these hospitals do not get the profits, they can transfer the profits to related institutions such as churches. Why does the Government have to let non-profit-making bodies run the hospital?
Over the past thousands of years, Chinese medical services have not been provided by hospitals. They have been provided by clinics instead. In terms of the mode of operation, should Chinese medical services be provided centrally by a hospital in Tseung Kwan O or across the 18 districts with two or three additional Chinese medicine clinics in each district? In terms of the development of Chinese medicine, do we really think that the problem can be resolved by establishing a Chinese medicine hospital? Development of Chinese medicine has to be supported by scientific research as well. Will the scientific research project be a success and does it need any subsidies from the public coffers? Let me give an example. If a scientific research project results in the development of a Chinese medicine which can treat cancers, it may even get a Nobel Prize. If an international pharmaceutical firm develops a medicine which is really effective, that medicine alone can bring in profits amounting to several billion US dollars a year. Should the Government put more resources in formal scientific research?
Furthermore, to my regret, sometimes when I suggest my friends in the Chinese medicine sector that the efficacy of Chinese medicine should be proven with the help of modern medical sciences such as molecular physics or statistics, they would give me a very interesting response. They said that the practice of Chinese medicine is individualistic and it differs with every practitioner. If that is the case, it will be awful. Even if there is a superb Chinese medical practitioner who can work miracles, he is all alone. As the skills and knowledge cannot be passed on, it will be hard to foster them.
I have used up 30 minutes in delivering this speech alone. President, I so submit. |