Introduction

The Health, Welfare and Food Bureau (HWFB) and the Health and Medical Development Advisory Committee (HMDAC) released the document "Building a Healthy Tomorrow - a Discussion Paper on the Future Service Delivery Model for our Health Care System" in July 2005 for public consultation.¹ This was the first Government attempt to address our health care system as a whole by emphasizing the relationship and defining the respective roles of primary, secondary and tertiary care. The system thinking and comprehensive approach demonstrated in this paper is commendable, which gives the new health care model some hope of success in moving our health care delivery system forward.

An outstanding feature of the new health care delivery model is the emphasis that the family doctor should be responsible for providing the majority of the preventive, medical and rehabilitative care for the population. It also recommended that every person should have his/her family doctor who can assure the most appropriate health care is provided. However, there are a few issues that need to be clarified and established before the new model can serve the purpose of building a healthy tomorrow so that there will be "health for all in the 21^st Century".²

Primary health care and the family doctor often go hand in hand because the latter is the key providers of the former, but they are not interchangeable. It is important to differentiate between the two right from the beginning of the design of a health care delivery model so that roles and functions of each player and service can be defined. The view that "¼ a family doctor can be ¼.. any other specialist"¹ is misleading to the profession and public. This could even become a laughing stalk of the international professional community. Primary health care is the first point of contact for professional health services, which is normally best provided by the family doctor although some people may choose to consult the Accident and Emergency department or a private specialist first. A patient scenario may illustrate the differences between the family doctor and other primary health care doctors better.

"Mr. Joe Yeung is a 45-year old insurance broker who is under a lot of work stress recently because his company management has set some new business targets that he has difficulty in meeting. He is not sleeping well at night and feels rather tired in the day. He starts to think that he cannot cope with his work because his health is failing. He looks for signals of illnesses from his body and he noticed that he has some belching. So he goes to see the doctor.

If Joe consults the family doctor first, he will be evaluated on not only his belching but also his underlying concerns, psychological state and social situation. The family doctor will be able to detect his work stress in addition to his presenting symptom. Apart from deciding on whether further investigation and drug treatments for the belching are needed, the family doctor will also look for any psychological disease and offer counselling to Joe's stress. After seeing the family doctor, Joe will try to solve his problem by stress management instead of using the health service.

If Joe consults a gastroenterologist first, he will most likely be subject to an upper GI endoscopy and H pylori testing, which will most likely be negative. The gastroenterologist will reassure him that there is nothing wrong with him and prescribe some empirical symptomatic treatment. Joe still feels tired and starts to look for other symptoms, shop for doctors and undergo further investigations to find out what is wrong with him."

It is clear from the above scenario that the outcome can be very different if a patient consults the family doctor or other specialists in primary health care, and not all specialists can be family doctors. The family doctor is a doctor who provides primary, comprehensive, whole-person, and continuing care. The provision of comprehensive and whole-person care differentiates the family doctor from other primary health care doctors and specialists. Comprehensive (full-service) primary health care caters for patients of any age or gender, and illnesses related to one or more body systems.

Evidence on the contribution of the family doctor to the health of the population is accumulating. Countries that ranked top in the performance of their health care systems have strong primary health care provided by general practitioners or family doctors.³ An increase in the family doctor to general population ratio has been shown to be associated with a decrease in mortality, saving in health care cost, and earlier diagnosis of cancers.^4-8 Data from Hong Kong, the United Kingdom and North America have shown that family doctors can deal with over 90% of all health problems in the community but such data are not available for other primary health care providers.^9-12 Similar evidence is lacking on the effectiveness of other specialists in the provision of primary health care.

In the Joint WHO-WONCA (World Organization of Family Doctors) Conference in 1994, the World Health Organization (WHO) formally endorsed the contribution of family medicine to medical practice and education.¹³ The World Health Assembly 1998 concluded that access to comprehensive, essential, quality health care to be the indicator of 'Health for all in the 21^st Century',² which coincide with the concepts of family medicine. Quality means fit for the purpose, the family doctor's broad knowledge base is most fit for the delivery of comprehensive care, and his/her emphasis on whole-person care ensures that essential care is provided tailor-made to each individual patient.

The rapid development of many life-saving technologies during the 20^th Century has ironically perpetuated sick lives more than healthy ones, which Ernest Gruenberg calls 'the failures of success'.¹⁴ The population is rapidly aging resulting in many people with multiple diseases and disabilities living in the community. The rising cost of secondary care requires a shift of a larger proportion and health problems to be treated in primary care. The rapid change in the socioeconomic structure in Hong Kong has led to many psychosocial problems which often co-exist with physical diseases. The morbidity pattern presenting to primary health care is changing, coughs and colds will no longer be the bread and butter but chronic diseases and psychological problems are going to be the most common reasons for consultations in primary health care.

A very important function of primary health care is to save health care resources by gate-keeping expensive secondary and tertiary cost. The more primary health care can do, the more the health care system can save. On the other hand, ineffective primary health care will cost the health care system more because it can cause more illnesses from inappropriate or delayed treatment, and wastes resources if it cannot solve the health problems of the patient. The family doctor must be able to deal with a wide range of illnesses ranging from medically unexplained physical symptoms to multiple complex chronic diseases in order to meet the challenges of tomorrow's primary health care. An emerging role of the family doctor is the management of psychological problems which is becoming a major cause of ill health.

The Harvard report in 1999 revealed the painful reality that the quality of primary health care in Hong Kong was closer to that of a developing country although our wealth topped the world owing to a long neglect of training and quality assurance for doctors in primary health care.¹¹ The view that basic medical education could adequately prepare a doctor to deal with the "simple" problems in primary health care is much dated because primary health care is becoming as complex as, if not more than, secondary care. It is not hard to understand that a specialist in family medicine with six years of formal vocational training and demonstration of competence at the standard of a specialist is likely to be able to provide a wider range of services and a higher standard of primary health care than someone with less training. It is to be expected that a primary health care doctor without any postgraduate vocational training is unlikely to be as effective as a family doctor who has been trained. For several years now, there is an international trend towards compulsory formal vocational training in Family Medicine/General Practice as well as assessments before independent practice in primary health care. The Government and public in Hong Kong have to decide on the standard of primary health care that every citizen can enjoy, and must be prepared to make the appropriate investment in the training of primary health care doctors in family medicine.

The Discussion Paper has stressed that health care delivery requires a system approach and the need of a clear definition of the roles and function of each component in the system. It is also important to note the mutual influence that each component of the system has on each other. Changes in one component will not occur unless corresponding changes are made in the other components. If primary health care is going to take up more roles and responsibilities in health care delivery, secondary and tertiary care must help by facilitating the transfer of care. A system of efficient two-way transfer of patient information between primary, secondary and tertiary care is an essential but insufficient requirement. The other very important, although some people may find it a bit abstract, requirement is a trusting attitude towards the family doctor from both the public and the profession. Share care, in contrast from discharge programmes, may perpetuate the public and professional's lack of trust of the family doctor, duplicate resources and confuse patients. It should be limited only to selected patients with conditions that concurrent primary and secondary care would be more beneficial than either one alone.

Appropriate transfer of care from secondary to primary health care can benefit not only the patients but also the specialists who can then concentrate on the provision and development of their specialized care. The family doctor can enhance the effectiveness of not only primary health care but that of secondary and tertiary care by counselling patients on treatment adherence. On the other hand, transfer of patients from secondary to primary health care without the proper infrastructures in communication and attitudinal changes is likely to cause dissatisfaction in patients and the profession, and wastage of resources from duplication of services.

Although primary health care is less costly than secondary and tertiary care, it requires the necessary additional resources for the additional services. The expanded primary health care services can be costly especially for patients who require investigations and long-term treatments. It is unrealistic to expect patients willing to pay for investigations and treatments if they can enjoy free services from the hospital. A system of means testing for fair allocation of public health care dollars must be in place before any attempt to shift the services from secondary to primary health care. Purchase of services from the private sector can be subject to abuse under the "Inverse Care Law",¹⁵ unless there are very clear criteria on who and what services are included.

Management guidelines are useful and can assure quality of care but top-down protocols from hospital specialist or the Government often lack validity for application in primary health care. Guidelines for primary health care should be based on evidence from primary health care but such research evidence in Hong Kong is very limited. There is an urgent need for more local research in primary health care, designated funding has been shown to be an effective driver of primary health care research, as shown by the experience in the United Kingdom and Australia.^16-18

Meeting the challenges of building a healthy tomorrow

The public and the profession need to be prepared for the changes of a new health care delivery model. The most important driver of change is motivation. The public is more likely to be motivated to use primary instead of secondary care if the care is effective in addition to being less expensive and easily accessible. Family doctors with adequate training are most fit for the provision of effective primary health care because they can provide comprehensive care by looking after patients of any age, gender or illness, and provide full-services including prevention, treatment and rehabilitation. A major challenge that Hong Kong is facing is how to make up for the deficiency in family medicine training before 1997, so that each citizen can find a family doctor. It will not be possible to have all family doctors trained up to the specialist standard in the next few years but this may be our ultimate goal to be reached in 20 years' time. Continuing professional development is an alternative to formal vocational training for practising primary care doctors who can study for postgraduate diplomas or higher qualifications in Family Medicine/General Practice or continue to improve through self-directed learning. The Government, the public and the profession must invest in training and continuing professional development now if we want our population to have a healthy tomorrow.

Effective health care must be evidence-based and there is an urgent need for more research in primary health care in Hong Kong. An investment in primary health care research funds will be paid off by better health for the population, and saving in health care cost from more effective primary health care services. Research evidence needs to be readily available and accessible to all doctors. The internet is a very efficient means of information dissemination. Government support for practice computerization and access to medical databases has been shown to be an effective way of enhancing the quality of primary health care.

The family doctor has important roles and responsibilities in building a healthy tomorrow for the population by providing comprehensive, essential, and whole-person quality primary care. A primary-care based health care delivery model can improve people's health and save health care cost provided primary care is effective. Primary health care is becoming more complex, adequate training in family medicine is essential to prepare doctors for the challenge. There is an urgent need for research in primary health care so that practices can be evidence-based.

Key messages

1. The provision of comprehensive, whole-person and essential care differentiates the family doctor from other specialists.


2. The family doctor is most fit for the purpose of primary health care.


3. Primary health care must be effective and of high quality in order to serve its roles and functions.


4. Adequate vocational training and research in primary care are essential pillars of quality primary health care.