My Question on the Strategic Review on Healthcare Manpower Planning and
Professional Development Report
Finally, the Steering Committee
on Healthcare Manpower Planning and Professional Development, which was formed
in 2012, has published its report (the Report) on the Strategic Review on
Healthcare Manpower Planning and Professional Development (the Review) in June
2017. The Review is very important. As stated by the Chairman of the Steering
Committee, Dr. KO Wing Man, “following
the conclusion of the Review, Government will soon embark on an updating
exercise on manpower projections in consultation with the relevant stakeholders
and invite each and every of the Boards and Councils for healthcare professions
to submit detailed and concrete proposals for implementing the recommendations
of the Review taking into account the unique circumstances of individual
professions. We shall take all necessary
steps to bring supply and demand of healthcare professionals into board equilibrium
over time.” This is in line with the
aims of the Review, which are to make recommendations to: “cope with the anticipated demand for healthcare manpower; and
facilitate professional development of healthcare professions.”
I must confess that I am none the
wiser after reading the Report. I would
like to share some of my observations and doubts with readers. I shall concentrate on the parts concerning
the manpower planning of doctors. I
shall make references to the content of the Report as much as possible.
Training on evidence-based
medicine teaches us that when reading a report, we need to study the
methodology so as to appraise the validity of the results; to consider whether
the findings support the conclusion drawn; and to be aware of the assumptions
and limitations of the report.
Basically, the approach of the
Review is to calculate and to predict the demand and the supply of doctors in
future years, and then “to quantify the
difference between the projected demand for and supply of healthcare professionals
i.e. projected manpower gap in terms of full time equivalents (FTEs).” For the demand model, “historical utilization data and the Hong Kong demographic projections
(2004-2015) were used to project age-, sex-specific utilization volumes. These projected volumes were then converted
into FTEs and subsequently further adjusted for externalities and policy
interventions.” “The supply model is a
non-homogenous Markov Chain Model, where workforce systems are represented as ‘stocks
and flows’. These projected volumes were
then converted into FTEs and subsequently further adjusted for externalities
and policy interventions.”
I would say that the model is
beyond comprehension to all doctors. This
is because apart from the fact that the model is complex, there is no intention
for the Report to explain to readers in any detail how the model works. To me, the supply arm is relatively simple. The majority of doctors come from the 2
Universities and the numbers are highly predictable. For non-locally trained doctors, it is
unlikely to have any substantial changes in number unless there are major
policy changes. The Report does not
recommend any such major policy changes. “The
Steering Committee considers that while measures should be taken to facilitate
experienced non-locally trained doctors to come and practice in Hong Kong, the
quality and competency level of these doctors should not be compromised. MCHK should continue to be entrusted to uphold
the professional standards of doctors in order to safeguard patient safety and
interest in Hong Kong.” Recommendations
to increase supply include increasing the number of UGC-funded training places,
retaining doctors to work in HA, recruiting non-locally trained doctors through
limited registration and established mechanism.
For the demand part, “the projection for doctors takes into
account the expected utilization rates of services drawn from HA and DH for the
public sector, and those of private hospitals as well as the Thematic Household
Survey conducted by the Census and Statistics Department for the private
sector. Demand from the academic,
teaching and training sector has also been considered. The projection has been adjusted for the
impact of externalities such as the latest development of public and private
hospitals and introduction of the Voluntary Health Insurance Scheme.” That sounds comprehensive. However, demand can be created. Expectations of the public can be managed. There can be no limit to the demand of
healthcare services. Therefore rationing
is always important in the fair and effective distribution of limited supply
and resources to meet theoretically unlimited demands. In the Report, there is no mention of
investigation into rationing of existing services, or how to manage expectation
of the public in the future. Facing a
relatively predictable and stable supply of doctors, it is irrational to just
try to recommend means to increase the supply of doctors without consideration
of managing the increase in demand.
From such model, it is predicted
that for the best guestimate, the manpower gap in FTE would be at 285, 500, 755
and 1007 in the year 2016, 2020, 2025 and 2030 respectively. However, the range for the 5th and
95th percentile would be 80 to 690, 320 to 989, 596 to 1296, and 829
to 1575 in the year 2016, 2020, 2025 and 2030 respectively. These calculations are based on an important
assumption. “The manpower situation at the base year (i.e. 2015) is assumed to be
at an equilibrium and the model takes into account known shortage in the public
and subvented sectors for healthcare professionals as at end of 2015.” So, to start with, it is assumed as a fact
that there is shortage of manpower in the public and subvented sectors. Against this important assumption, “the Steering Committee is mindful that the
private sector is more flexible in adjusting productivity in response to market demand. The Steering Committee also notes the
observations of some that there remains spare capacity in the private sector
and thus considers that the Government’s priority should be focused on filling
the manpower gap in HA, which provides nearly 90% of all in-patient services
and around 30% of primary care services in Hong Kong.” Interestingly, there is no recommendation
on how to make use of the flexible private sector with surplus of manpower.
Last but not the least, let us
look at the limitations of the Report. “Healthcare manpower projection is an
extremely complex mission. There is no
universal model for projecting healthcare manpower whether in the literature or
among the jurisdictions surveyed.” “The
changes in the patterns of referral, sector of service delivery (public and
private), technological advancement, scope of practice, feminization of the
workforce, healthcare policy and service delivery regulation affect constantly
the demand for healthcare service, while changing population demographics,
inter-regional and inter-sectoral (public/private) movement of healthcare
professional and patients as well as healthcare utilization patterns further
complicate manpower projection.” “Manpower
projection is also a highly data-intensive activity. Although public sector in-patient and
outpatient data for manpower projection is readily available, a substantial
proportion of patient care occurs in the private sector for medical and social
care where utilization data are scattered, less complete, or not readily
available. The lack of normative
standards defining productivity is also a major impediment to workload
analysis.”
Actually, the Report has stated
clearly how the results should be used. “Because of the nature of manpower
projection and the inherent limitations of the model itself, the projection
results should be viewed in perspective. In interpreting the projection results, we
should focus on the trend rather than the absolute gap. The medium to long-term projection could
change significantly if events unknown now happen in future.”
