321
EDITORIALS
Health service doldrums in
Hong Kong Among all its other troubles, Hong Kong has to contend with a crisis in the health service. Historically, the Government Medical and Health Department had its origins in the old colonial army medical service. This became part of the civil service and concentrated on public health services and the building of large cheap regional hospitals directed from a remote and hierarchical central bureaucracy. The hospitals are staffed by a tiny elite of consultants supported by junior medical doctors including a subconsultant senior medical officer (SMO) grade. There has never been a Government-supported primary health care service, and since hospital care is virtually free many patients present directly to accident and emergency departments. Inpatient admissions have reached 11 000 a month in some hospitals, with hundreds of patients on camp beds in hospital corridors. Doctors and nurses are overstretched and have poor career prospects. Working conditions are dismal, with shabby and overcrowded accommodation, few secretaries, no ward clerks, rudimentary libraries, and disgusting toilets. Staff are promoted mainly by seniority and are moved without notice: surgeons may be posted to psychiatry and physicians to midwifery. (This is no joke: since civil servants change from housing to transport without blinking an eyelid they cannot see any problem in moving doctors from cardiac to surgery orthopaedics.) Medical and senior superintendents hospital administrators into disappear overnight public health or central administration, and Hong Kong must be the only place in the "free" world where medical schools cannot appoint their own junior medical staff. Anyone who voices even the mildest criticism of all this in public is likely to be banished to a mother and baby clinic on the outlying islands. As if that were not enough, there is a serious
shortage. Official estimates in 1988 showed a shortage of 500 hospital doctors and forecast a worsening to 800 in 1994. Several large new hospitals are under construction, requiring an extra 140 doctors and 500 nurses for this year alone. The output of the medical, nursing, and technical schools can hardly keep pace with projected growth, and is hopelessly inadequate in the face of staff losses. General dissatisfaction has led to continuing defections to the private sector or to jobs abroad, and the prospect of the Chinese takeover of Hong Kong in 1997 has made the trickle a deluge. The annual wastage rate of doctors is now 12% (last year 183 left the service), and of nurses, 9%. Foreign recruitment seminars (especially for nurses) are held almost monthly, and many doctors, unable to obtain medical jobs abroad but wealthy from private practice, plan to emigrate through business investment. The staff who are leaving tend to be the most senior and best qualified, and a survey by the Government Doctors’ Association suggests that up to 70% of SMOs and 55% of consultants will leave Hong Kong by 1997. Strikes and threats of strikes among doctors, nurses, and midwives have bedevilled the service for the past eighteen months and eventually caused the Government to remove the then Secretary for Health and Welfare (an almost unprecedented event for this unelected administration) and to replace him with Mrs Elizabeth Wong, formerly the Secretary for Social Services. Mrs Wong has adopted a more sympathetic stance towards the doctors, and the Government has arranged a temporary 10% rise in salaries, with promises to uncouple medical pay from civil service scales, increase the number of consultant posts, and allow limited rights to private practice. The junior doctors publicly hooted with derision but took the money anyway and seem to be mollif ed for the manpower
time being. These unhappily momentous events have come at a time when great changes are about to be implemented in the health service. In 1985, a report commissioned
322
by the Government from an Australian consultancy firm (the Scott Report) recommended the splitting of the Medical and Health Department into separate public health and hospital services departments, with the hospitals administered by a hospital authority independent of the civil service. The main administrative unit is to be the region, centred on the large regional hospitals which will be free to develop their own policies and to hire and fire their own staff. The proposals also bring the semi-independent subvented (Government-assisted) hospitals under the umbrella of the authority. Sir S. Y. Chung has been appointed head of the provisional authority, which will be replaced by a permanent one in April. Cynics regard the bisection of the Medical and Health Department as a way of doubling the central bureaucracy, but optimists take heart from the fact that the provisional authority recently toured the regions to see things at first hand-although this was the first time that many members of the authority had ever set foot in a public hospital, and the visits seemed more like photo-opportunities than a real attempt to understand the grassroots difficulties. Yet another commissioned report, this time on postgraduate medical education, was presented to the Government by Prof Keith Halnan, of London, in 1988. (There seems to be so much internecine warring in Hong Kong that no-one would ever accept a report by local experts, even in the unlikely event that such experts could agree among themselves.) Hong Kong has no organised medical postgraduate training of its own and medical graduates tend to train abroad and take foreign (especially British and Australian) postgraduate qualifications. For many reasons, not least political, the Halnan report concluded that Hong Kong should establish its own academy of medicine to supervise training and to set and examine its own postgraduate qualifications. The academy will be independent of the Government and will consist of a number of colleges of medicine, surgery, &c (although the &c has already caused much heartache among the smaller specialties such as paediatrics, orthopaedics, and anaesthetics, which would dearly like colleges of their own). Prof David Todd, formerly professor of medicine and dean of the medical faculty at Hong Kong University, has been appointed president of the academy, which will be inaugurated in 1991. These developments are much to be welcomed, and with appointees of the calibre of Sir S. Y. Chung and Professor Todd there is cause for optimism. But no discussion of anything in Hong Kong can get very far without raising the twin questions, what about money and what about China? If there is to be any sort of headway in solving the crisis in the health services, money must be made available to improve training, improve conditions, improve pay, and improve career prospects. Unfortunately, while Hong Kong has plenty of money it has decided to spend most of it on a new airport.
This decision is actually part of the China question, since the gigantic and highly visible project will generate confidence and attract foreign investment. The trouble is that hospitals and runways seem to be incompatible. The day after the airport project was announced the Government cancelled many of the new hospital posts that had been promised for this year.
Since the Tienanmen Square massacre on June 4, 1989, nothing has boded well for the future in Hong Kong, and that is why so many doctors, nurses, and technicians are leaving. If anything, China has become more belligerent as each month has passed, and since the European communist leaders omitted to kill off their own protesters, thereby losing power, privilege, and even their own so much more important lives. "I told you so" grunted Mr Deng with chilling smugness, proceeding to rattle his machine-guns and maintain an even harder line against any kind of democratic reform in Hong Kong. Despite the Sino-British agreement that the structure of Hong Kong society will remain unchanged for fifty years after 1997, we now hear that those with the right of abode in foreign countries will no longer be eligible for senior administrative positions after the handover. China is unworried by the Hong Kong braindrain because she believes she can supply plenty of professionals to fill the gaps. (The journalist Jim Biddulph recently wondered aloud why the Chinese think that an official who has failed to make a success of a pig farm in Tianjin will do any better with the complex economy of Hong Kong.) What chance that the chairman of the hospital authority will have to be a Chinese national in 1997? What chance the president of the academy of medicine? The deans and professors of the medical schools? The medical superintendents? The hospital consultants? Does anyone want to bet how many qualified doctors and nurses will be left in Hong Kong in 1997? Mr Deng, the answer rests almost entirely in your hands.
positively hysterical
Coal dust and
compensation
"All scientific work is incomplete whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us the freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand at a given time"-A. BRADFORD HILL. The environment and disease: association or causation? Proc R Soc Med 1965; 58: 295-300.
Knowledge of the harmful effects of coal dust on the lungs has expanded considerably in the past two decades. As a result, the many interested parties in the UK who had hoped for a fresh approach by the Department of Social Security to the compensation of disabled coal miners will be bitterly disappointed by the latest edition of the Department’s guidelines. The
EDITORIALS
Health service doldrums in
Hong Kong Among all its other troubles, Hong Kong has to contend with a crisis in the health service. Historically, the Government Medical and Health Department had its origins in the old colonial army medical service. This became part of the civil service and concentrated on public health services and the building of large cheap regional hospitals directed from a remote and hierarchical central bureaucracy. The hospitals are staffed by a tiny elite of consultants supported by junior medical doctors including a subconsultant senior medical officer (SMO) grade. There has never been a Government-supported primary health care service, and since hospital care is virtually free many patients present directly to accident and emergency departments. Inpatient admissions have reached 11 000 a month in some hospitals, with hundreds of patients on camp beds in hospital corridors. Doctors and nurses are overstretched and have poor career prospects. Working conditions are dismal, with shabby and overcrowded accommodation, few secretaries, no ward clerks, rudimentary libraries, and disgusting toilets. Staff are promoted mainly by seniority and are moved without notice: surgeons may be posted to psychiatry and physicians to midwifery. (This is no joke: since civil servants change from housing to transport without blinking an eyelid they cannot see any problem in moving doctors from cardiac to surgery orthopaedics.) Medical and senior superintendents hospital administrators into disappear overnight public health or central administration, and Hong Kong must be the only place in the "free" world where medical schools cannot appoint their own junior medical staff. Anyone who voices even the mildest criticism of all this in public is likely to be banished to a mother and baby clinic on the outlying islands. As if that were not enough, there is a serious
shortage. Official estimates in 1988 showed a shortage of 500 hospital doctors and forecast a worsening to 800 in 1994. Several large new hospitals are under construction, requiring an extra 140 doctors and 500 nurses for this year alone. The output of the medical, nursing, and technical schools can hardly keep pace with projected growth, and is hopelessly inadequate in the face of staff losses. General dissatisfaction has led to continuing defections to the private sector or to jobs abroad, and the prospect of the Chinese takeover of Hong Kong in 1997 has made the trickle a deluge. The annual wastage rate of doctors is now 12% (last year 183 left the service), and of nurses, 9%. Foreign recruitment seminars (especially for nurses) are held almost monthly, and many doctors, unable to obtain medical jobs abroad but wealthy from private practice, plan to emigrate through business investment. The staff who are leaving tend to be the most senior and best qualified, and a survey by the Government Doctors’ Association suggests that up to 70% of SMOs and 55% of consultants will leave Hong Kong by 1997. Strikes and threats of strikes among doctors, nurses, and midwives have bedevilled the service for the past eighteen months and eventually caused the Government to remove the then Secretary for Health and Welfare (an almost unprecedented event for this unelected administration) and to replace him with Mrs Elizabeth Wong, formerly the Secretary for Social Services. Mrs Wong has adopted a more sympathetic stance towards the doctors, and the Government has arranged a temporary 10% rise in salaries, with promises to uncouple medical pay from civil service scales, increase the number of consultant posts, and allow limited rights to private practice. The junior doctors publicly hooted with derision but took the money anyway and seem to be mollif ed for the manpower
time being. These unhappily momentous events have come at a time when great changes are about to be implemented in the health service. In 1985, a report commissioned
322
by the Government from an Australian consultancy firm (the Scott Report) recommended the splitting of the Medical and Health Department into separate public health and hospital services departments, with the hospitals administered by a hospital authority independent of the civil service. The main administrative unit is to be the region, centred on the large regional hospitals which will be free to develop their own policies and to hire and fire their own staff. The proposals also bring the semi-independent subvented (Government-assisted) hospitals under the umbrella of the authority. Sir S. Y. Chung has been appointed head of the provisional authority, which will be replaced by a permanent one in April. Cynics regard the bisection of the Medical and Health Department as a way of doubling the central bureaucracy, but optimists take heart from the fact that the provisional authority recently toured the regions to see things at first hand-although this was the first time that many members of the authority had ever set foot in a public hospital, and the visits seemed more like photo-opportunities than a real attempt to understand the grassroots difficulties. Yet another commissioned report, this time on postgraduate medical education, was presented to the Government by Prof Keith Halnan, of London, in 1988. (There seems to be so much internecine warring in Hong Kong that no-one would ever accept a report by local experts, even in the unlikely event that such experts could agree among themselves.) Hong Kong has no organised medical postgraduate training of its own and medical graduates tend to train abroad and take foreign (especially British and Australian) postgraduate qualifications. For many reasons, not least political, the Halnan report concluded that Hong Kong should establish its own academy of medicine to supervise training and to set and examine its own postgraduate qualifications. The academy will be independent of the Government and will consist of a number of colleges of medicine, surgery, &c (although the &c has already caused much heartache among the smaller specialties such as paediatrics, orthopaedics, and anaesthetics, which would dearly like colleges of their own). Prof David Todd, formerly professor of medicine and dean of the medical faculty at Hong Kong University, has been appointed president of the academy, which will be inaugurated in 1991. These developments are much to be welcomed, and with appointees of the calibre of Sir S. Y. Chung and Professor Todd there is cause for optimism. But no discussion of anything in Hong Kong can get very far without raising the twin questions, what about money and what about China? If there is to be any sort of headway in solving the crisis in the health services, money must be made available to improve training, improve conditions, improve pay, and improve career prospects. Unfortunately, while Hong Kong has plenty of money it has decided to spend most of it on a new airport.
This decision is actually part of the China question, since the gigantic and highly visible project will generate confidence and attract foreign investment. The trouble is that hospitals and runways seem to be incompatible. The day after the airport project was announced the Government cancelled many of the new hospital posts that had been promised for this year.
Since the Tienanmen Square massacre on June 4, 1989, nothing has boded well for the future in Hong Kong, and that is why so many doctors, nurses, and technicians are leaving. If anything, China has become more belligerent as each month has passed, and since the European communist leaders omitted to kill off their own protesters, thereby losing power, privilege, and even their own so much more important lives. "I told you so" grunted Mr Deng with chilling smugness, proceeding to rattle his machine-guns and maintain an even harder line against any kind of democratic reform in Hong Kong. Despite the Sino-British agreement that the structure of Hong Kong society will remain unchanged for fifty years after 1997, we now hear that those with the right of abode in foreign countries will no longer be eligible for senior administrative positions after the handover. China is unworried by the Hong Kong braindrain because she believes she can supply plenty of professionals to fill the gaps. (The journalist Jim Biddulph recently wondered aloud why the Chinese think that an official who has failed to make a success of a pig farm in Tianjin will do any better with the complex economy of Hong Kong.) What chance that the chairman of the hospital authority will have to be a Chinese national in 1997? What chance the president of the academy of medicine? The deans and professors of the medical schools? The medical superintendents? The hospital consultants? Does anyone want to bet how many qualified doctors and nurses will be left in Hong Kong in 1997? Mr Deng, the answer rests almost entirely in your hands.
positively hysterical
Coal dust and
compensation
"All scientific work is incomplete whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us the freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand at a given time"-A. BRADFORD HILL. The environment and disease: association or causation? Proc R Soc Med 1965; 58: 295-300.
Knowledge of the harmful effects of coal dust on the lungs has expanded considerably in the past two decades. As a result, the many interested parties in the UK who had hoped for a fresh approach by the Department of Social Security to the compensation of disabled coal miners will be bitterly disappointed by the latest edition of the Department’s guidelines. The
![[Hong Kong]health database in Hong Kong.](/assets/img/hold.png)
