I read a proposal by the Primary Care
Office on a pilot project of setting up a community health center. Actually community health center is nothing
new. By definition, it is a health
center in the community, though people nowadays would say that a health center
needs to be multidisciplinary. To me, I
would consider the Sai Ying Pun Jockey Club Clinic, referred to by local people
as the “Government Civic Hospital” and has been there for decades, is a
community health center. There are
general out-patient clinic and different specialty clinics including maternal
and child health center, dermatology and social hygiene clinic and chest clinic
in a multi-storied building. There are
also X-ray and laboratory services. If
you think that there must be other healthcare disciplines other than medical
doctors, then there is the David Trench Rehabilitation Center nearby. There are physiotherapy, occupational
therapy, psychogeriatric day care, psychiatric community nursing, general
psychiatric day care and medical social services.
The Hospital Authority thought
differently. In 2012 it announced the
opening of its first community health center in Tin Shiu Wai. It was described as “the first health centre
with design based on the Government's primary care development strategy and
service model”. And, “it is a one-stop
centre where people receive comprehensive primary care services by
multi-disciplinary primary care professionals in the community. The general out-patient clinic on the first
floor provides around 200 consultations per day. Patients visiting the Tin Yip Road health
centre are referred to the multi-disciplinary primary care professionals
(including nurses, physiotherapists, occupational therapists,
prosthetist-orthotists, dieticians and optometrists) located on the second
floor to receive appropriate intervention and follow-up services. The centre also collaborates with
non-governmental organisations to provide health-care education and
psychological counselling services”.
Let’s first skip the aims and objectives
of setting up community health centers.
Although such objectives serve for navigation during the night, they are
like stars that are difficult, if not impossible, to reach. Afterall, it is how you communicate with
Einstein and how you build the rockets that matter in your project to
Mars. We look at the operational
aspects. What are the differences
between the Tin Shui Wai Community Health Center and the Government Civic
Hospital? Or how about adding a general
out-patient clinic to the David Trench Rehabilitation Center?
One obvious difference is that doctors
from the general out-patient clinic can directly refer patients to services of
other healthcare workers at the clinic.
However, putting all services spatially in the same building does not
benefit patients. Patients are unlikely
to go directly from general out-patient to other clinics in the same day. They have to wait for another
appointment. Unless patients are able to
see the same doctor each time and more time is allowed for each consultation,
the concept of family doctor and continuous primary care do not apply. If just for direct referral from general
out-patient clinic, this can easily be achieved by opening up the existing
services to accept direct referrals.
Instantly, we have many community health centers.
The pilot project of the Primary Care
Office was different, as it said. I
summarized the differences from what I read as follows:
- There is no medical doctor in the center.
- It accepts referrals from doctors in private practice.
- It targets more on prevention than cure. Thus the scope of services includes risk assessment and chronic disease management; patient empowerment programmes; and health promotion services.
- A case-coordinator, likely a senior nurse, will lead the primary healthcare team there.
- The center will be led by a non-government organization.
Again, I am more interested in how it
works, or how it is going to work. All
disciplines of healthcare workers exist in the private market already. The opening of a community health center is
unlikely to create more physiotherapists or podiatrists. Instead, it employs its own healthcare
workers and theoretically it will decrease the supply of workers in the private
market. This shortage also applies to
senior nurses. The concept of having a
senior nurse as case-coordinator is adorable.
However, to fulfill the objective of continuous primary care, the same
case-coordinator should follow-up his own patients. The center will need to have many
case-coordinators. They are then
overlapping the job of family doctors who are supposed to know their patients
well and to lead a primary healthcare team.
Preventive care does not come cheap. High rents are eating away the major share of
profits in the private market. Charges
for each visit for any healthcare worker are already higher than visiting
family doctors. In the community health
center, there is the addition of a case-coordinator. That will incur extra costs. The case-manager is going to identify needs
of patients and extra services are expected.
Why would building a community health center change the health seeking
behavior of Hong Kong citizens? How is
the center to compete with other healthcare workers in the private market?
The answer could not be found in the
document I read. So I asked. The right question usually gives you the gist
of the matter. The
community-health-center-to-be will be funded by the government (and thus you
and me) and will be highly subsidized.
The intended charge for each visit is around $60, or in-line with other
out-patient clinic charges. It is always
an ideal to provide comprehensive and continuous preventive care to all
citizens. However, ideals never work in
real world. Money is usually the
limiting factor. There is no need to go
again into the healthcare system, budgeting and rationing. The Primary Care Office might argue that the
community health center targets high risk patients. Nonetheless, that would include all patients
with chronic illnesses, all smokers, all overweight people and all the
elderly. I guess that covers more than
half of the population. Another possible
outcome is that the center turns out to be no different from other clinics run
by the Hospital Authority where patients get routine healthcare services at an
out-of-proportionally low cost. In that
case, the same effect can be achieved by just opening up the existing clinics
to accept referrals from private medical practitioners.
I wish that this community health center
will bring us to Mars, or will bring us one step nearer to Mars, or at least
will point our way to Mars. I hope it
will not turn out to be trucks loading patients to watch movies on stories
about Mars.
(Source: HKMA News May 2017)
