Hong Kong Med J 2023 Oct;29(5):375–7 | Epub 12 Sep 2023
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
EDITORIAL
Shaping the ‘Family Doctor for All’ system through the Chronic Disease Co-Care Pilot Scheme
Esther YT Yu, FHKAM (Family Medicine), FRACGP; Tony KH Ha, FHKAM (Community Medicine), FRACMA; FC Pang, FHKAM (Medicine), FHKAM (Community Medicine)
Primary Healthcare Office, Health Bureau, Hong Kong SAR Government, Hong Kong SAR, China
Corresponding author: Dr Tony KH Ha (tkhha@healthbureau.gov.hk)
Introduction
Type 2 diabetes mellitus (DM) and hypertension
combined were responsible for over 200 million
DALYs (disability-adjusted life years) worldwide,
representing the sum of years of life lost to premature
mortality plus years lived with disability arising from
these two highly prevalent conditions.1 2 Population-based
preventive measures (eg, promotion of
healthy lifestyles and targeted screening of
at-risk individuals) followed by early team-based
intervention have been effective strategies for
reducing the associated morbidity, mortality, and
healthcare burden.3 4 In countries with mature
primary healthcare systems, these services are led by
family doctors (ie, general practitioners) who partner
with multidisciplinary healthcare teams to provide
personalised, continuous, and comprehensive
holistic care for all community residents.5 6 7
Hong Kong has a treatment-oriented healthcare
system, in which 90% of hospital-based services are
provided by the public sector8 and approximately
50% of public general outpatient services are used
to manage DM and hypertension.9 Population-based
preventive care initiatives, such as anti-smoking
campaigns, the Colorectal Cancer Screening
Programme (CRCSP) and the Vaccination Subsidy
Scheme (VSS), have been successful but sporadic;
they have limited potential to empower participants
to pursue healthy living over life course. There is
no structured cardiovascular disease screening
programme in the public sector for most at-risk
citizens without their own family doctors,10 except
for older adults aged ≥65 years. Consequently, the
public healthcare system has been heavily strained
by the increasing prevalence of chronic diseases such
as hypertension and DM, along with complications
resulting from delayed diagnosis.
To improve healthcare system sustainability
and overall population health, the Government
recognises the urgent need to establish a prevention-oriented
primary healthcare system. The Primary
Healthcare Blueprint, issued in December 2022,
highlighted key areas of development needed to
address gaps in preventive care, continuity of care,
and community participation. An important strategy is to implement the ‘Family Doctor for All’ concept by
establishing a family doctor registration system: the
Primary Care Register (PCR).11 The PCR is intended
to build a recognition system for doctors who are
committed to providing comprehensive, continuous,
and holistic care to patients in the community; such
care ranges from preventive services to chronic
disease management.
Family doctors in the Primary Care Register
Private doctors have been providing approximately
70% of episodic outpatient care in the community.8
However, the health advocacy potential of family
doctors was not fully recognised by the public until
the expansion of family medicine training in 2004.
Beginning in 2013, the Government established a
Primary Care Directory (PCD) to recruit primary
care doctors (ie, any doctor in the private sector
who was committed to providing primary care)
for participation in various prevention-based
programmes, such as the VSS and the CRCSP. To
promote the community participation necessary
for desired health improvements, the Government
subsidised participants for each consultation
conducted within these programmes. Because
PCD registration was a prerequisite for receipt of
related subsidies, PCD doctors were often engaged
by the programme-based funding model. However,
this model does not promote continuity of care
if participants choose to consult PCD doctors
only for specific preventive care services, or if the
PCD doctors choose to only provide the specific
preventive care services to the scheme participants
during consultation.
To encourage community-based management
of stable chronic diseases and reduce the service
burden within the public healthcare sector, the
Hospital Authority (HA) implemented the General
Outpatient Clinic Public-Private Partnership
Programme as an outsourcing service, beginning
in 2014.12 However, the working relationship was
unilateral. As the funder, the HA would purchase
doctors’ services for specific tasks at prices
determined through a bidding process; as service
providers, PCD doctors would charge fees based on the service agreement. Benefits to patients were not
considered in this programme. Similarly, doctors’
efforts to deliver holistic care beyond the scope
of the service agreement were not appreciated or
supported. Both models regarded PCD doctors
as Government agents for service delivery and
contributed to the fragmentation of care. Thus, these
models failed to encourage the establishment of
long-term doctor-patient partnerships necessary to
enhance overall population health through patientcentric
care.
In contrast, the planned PCR recognises the
robust potential of family doctors. Under the PCR,
each citizen will be paired with their preferred family
doctor; each paired family doctor will be the only
doctor eligible to receive any subsidy allocated to the
paired patient, including existing programme-based
subsidies (eg, the VSS, the CRCSP, and the General
Outpatient Clinic Public-Private Partnership
Programme) and any future initiatives to support
primary healthcare. In addition to subsidies, efforts
to optimise holistic care require community-based
multidisciplinary team support for family doctors.
Community drug formularies will be established to
ensure that family doctors have access to common
medications at affordable prices, which will facilitate
long-term patient management. Community
nurses and allied health professionals at District
Health Centres will empower patients in leading
healthy lifestyles and managing their own health.
To encourage best practices, family doctors who
have fulfilled their preventive and chronic disease
care obligations, such as the provision of seasonal
influenza vaccination, will be rewarded through
additional payments.
The Chronic Disease Co-Care Pilot Scheme
The Chronic Disease Co-Care Pilot Scheme (the
Scheme) targeting DM and hypertension, which
will be launched in November 2023, represents the
prototype service model under the planned PCR.
People aged ≥45 years without a known diagnosis of
DM or hypertension will be eligible for enrolment
in a subsidised screening programme consisting of
laboratory tests and a medical consultation with
a paired family doctor registered in the current
PCD. Healthy participants will be offered education
regarding a healthy lifestyle and the opportunity to
undergo repeat screening every 3 years. Participants
with prediabetes, DM, and/or hypertension will
receive subsidised care, including laboratory
investigations for chronic disease monitoring, from
their paired family doctor and a multidisciplinary
team in the community.
To support PCD doctors in this new role, the
Scheme incorporates seven key components that
will shape the future primary healthcare system
when the Primary Healthcare Commission (PHC) is established in 2024. These components include:
(1) pairing of family doctors with participants;
(2) District Health Centres and their services;
(3) subsidised multidisciplinary services in the
community; (4) protocol-driven bi-directional
referral with designated medical specialist clinics
under the HA; (5) pay-for-performance incentives
for both participants and family doctors; (6)
community drug formularies to ensure that family
doctors have access to common medications at
affordable prices; and (7) uniform data sharing in the
Electronic Health Record Sharing System platform
with participant consent. An important objective of
the Scheme is to attract and build a pool of future
PCR family doctors who agree with our vision and are
committed to delivering quality primary care for our
fellow citizens. The ultimate goals of the Scheme are
to shift population-level health-seeking behaviour
from treatment-oriented to prevention-focused, to
encourage shared responsibility for personal health
at an affordable cost, to enable family doctors to
maintain continuity of care, and to improve health
for all.
Conclusion
The Scheme establishes a new framework for
primary healthcare involving family doctors and
community services. Upon establishment of the
PHC, a quality assurance system will be constructed
to guide clinical practice among healthcare
professionals via service quality standards and
reference frameworks. The PHC will also monitor
the performance of subsidised services and drive
continuous quality improvement through pay-forperformance
incentives. Additional subsidy tiers
will be established based on clinical complexity
and doctors’ qualifications. Hopefully, the Scheme
will encourage more doctors to enrol in the PCD,
and work as Family Doctors to provide continuous,
comprehensive, and patient-centric care to all
citizens.
Author contributions
All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
Conflicts of interest
The authors have declared no conflict of interest.
Funding/support
This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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