Dr Leung recently retired from his role as the longest-serving Chief Executive of the Hong Kong Hospital Authority (HK HA). He studied Medicine at the University of New South Wales, Australia and took the Master of Science (Occupational Medicine) programme here in NUS. The fundamentals of public health and occupational medicine that he learnt during this time led to a lifelong appreciation that medicine is more than just treating patients. More importantly, it is about taking care of communities and the whole of society.
This inspired Dr Leung’s career, setting up and leading the Centre for Health Protection in Hong Kong, and then going on to lead HA to meet the challenges of an ageing population living longer with multiple chronic conditions.
Dr Leung visited the Saw Swee Hock School of Public Health at the end of October to share with faculty and students some reflections from his distinguished career and how his time at NUS had instilled in him an appreciation of academia and fellowship. We sat down to chat with Dr Leung at the end of his short visit to the School.
Tell us about the Hong Kong health system.
Hong Kong people have a long life expectancy, currently one of the highest in the world (life expectancy at birth for men is 81.7 years and women 87.7 years). This is likely due to early health education, infectious disease prevention and management, and easy access to affordable health services.
Out of a total public service funding of HK$441 billion, health expenditure accounts for 18.3 per cent (HK$68.8 billion). On the high-level measures of performance, Hong Kong is one of the most efficient health systems in the world. Although there are private healthcare services, most people use the more affordable public hospital services. The public healthcare services cost little to the individual at the point of use as it is funded through a taxation model. There are also waivers for people who are in lower socioeconomic groups.
The Hong Kong Hospital Authority is a statutory administrative body, overseen and funded by the Food and Health Bureau. HA manages all the public hospitals and healthcare institutions in Hong Kong. It has been providing services to the public since the 1990s and currently manages 42 public hospitals and institutions, 48 specialist outpatient clinics and 73 general outpatient clinics. As of 31 March 2018, HA has a workforce of about 76,000 and some 28,000 beds. The HA facilities are organised into seven hospital clusters, which are geographically defined areas. Each cluster provides the core healthcare services, and some have specialist tertiary centres.
What are the key challenges facing the health system of Hong Kong?
1) An ageing population
Currently 17 per cent of the population in Hong Kong are over 65 years old, a trend set to increase rapidly in the coming decades. As the population ages, they suffer more chronic conditions such as diabetes, cancer and hypertension. Many older people can have two or more chronic conditions and require ongoing management and support for self-care. Much of this care delivery should be done as near as possible to where people live as this is more patient-centred and also a more efficient and effective use of healthcare services.
However, historic models of healthcare are often built around the episodic, hospital-based models of ‘triage – treat – discharge’. With an older population with multiple chronic conditions, there is a risk that poorly-managed chronic conditions result in people being continually readmitted to hospitals, which is not a good experience for the patient and uses unnecessary resources.
Similar to many other health systems, Hong Kong is tackling the challenge of shifting care nearer to the patient in communities and ensuring that this community-based care is coordinated and connected to the expertise in the hospitals when needed (such as older person specialists, endocrinologists and so on). Good progress has been made in setting up community elder health teams and centres, a model that will continuously evolve and is now seeking to credential primary care clinicians with specialist skills and expertise.
2) Rising costs
As with most health systems, there is the challenge of rising costs of new treatments and technologies. For example, targeted cancer treatments and surgeries are more effective but can be costlier and more time-consuming to deliver. Similar to other countries, Hong Kong has in place a system of evidence and cost review and assessment prior to the introduction of new treatments and technologies.
3) Workforce
There is a risk that, after training and investing in staff, they go on to work in the private sector or abroad. It is essential to ensure that we recruit and retain staff, and have in place a long-term sustainable workforce model. HA has a robust promotional system, which aims to reward and recognise performance and put in place opportunities for people to continuously learn skills and develop themselves.
What has enabled the success of HK HA?
The value system underpinning HA is critical; and this took time and perseverance to incorporate into practice. The core values of transparency, trust and cooperation have been central to our success in improving the quality and efficiency of healthcare. I’ll give you a few examples:
When I joined HA, we established a transparent reporting process around ‘sentinel events’: these are the major errors in care. It was hard work but worth the while to develop the system and cultivate a culture of positive learning from these events. It involved many face-to-face meetings with clinical leaders to get them on board and assure them that the primary aim of the system was to learn from events and not to blame clinicians. Ultimately, it came down to them trusting me to change the practice.
Clinicians within HA now work across all clusters to develop and agree on clinical service pathways and protocols, which are based on best practices (or clinical consensus, if the evidence is not yet available). There is now strong clinical governance and audit around the care pathways. There is the expectation that all will reach the average range and variation will be reduced, with the high performers supporting the lower performers by sharing good practices.
It was a long journey to get to the point of embedding a culture of transparency and using clinical audit of agreed care protocols as a performance improvement tool. HA started the process with broad guidelines and focused on engaging clinicians and services to ‘own’ and support them. Some services are further ahead and have highly detailed care pathways and protocols; others are still at an earlier stage. But every service needs to take this journey regardless, to get the buy-in of their staff and successfully incorporate it into their operational delivery.
The care pathway–driven model of delivery also inevitably leads to cross-service collaboration, which requires trust and transparency. Collaboration across services and sectors is needed now more than ever, because an ageing population requires the integration of care delivery within the community where older people and the frail live. There needs to be seamless and streamlined delivery within the community from primary, secondary and sometimes tertiary healthcare providers.
The HA cluster model has also been a positive force for improvement. While we rewarded leaders and senior staff for good performance, we also rotated them around the different clusters to promote a culture of continuous learning and collaboration. This also instilled loyalty to HK HA as a whole, rather than to a single cluster, which can lead to negative behaviours when clusters compete against each other.
Working in clusters allows for coordination and standardisation of quality, and HA also perpetuates the culture of transparency and trust throughout all clusters (including transparency of resource allocation, funding initiatives and so on). Health systems are intrinsically complex and what one hospital does will likely have an impact on another, so having a clear view across the system is essential for coordination and ensuring there is an effective and efficient system.
HA also facilitates the coordination of highly specialised services, such as ones that only have a small volume of patients, usually depend on highly specialised knowledge and skills, are high in cost, use rapidly changing technologies and treatments, or are high-profile and high-risk. This can mean pulling together the highly specialised service in one hospital, and moving staff and resources from others into a single team. There is often resistance to shifting services, but it can be successfully completed with transparency in decision-making and ensuring clinicians themselves review and engage with service change.
Our values of transparency and collaboration are also reflected in our approach to patient engagement. Patient involvement is strongly emphasised through the planning and delivery of care in HA. The patient has been a powerful voice for improvement. There are patient associations, training of patient representatives to be advocates, and patients sitting on committees within hospitals. This patient involvement has helped in the drive to transparency and a culture of improvement. There are also publicly available annual reports on quality and safety (covering topics such as medication errors, hospital-acquired infections, and speciality audits) that all patients can access. HA views the patient involvement and transparency of information as essential to building and retaining trust in services.
Reflecting on your career, what skills and approaches do you think are needed in public health leadership?
It comes back to values. Leadership in a health system is highly value-driven. People working in health want to help and provide comfort to people in need. As a leader, it is essential to recognise the values of staff and create a culture and organisation that is driven to improve — we will all end up using the system in the end.
The further into leadership your career takes you, the further you must step back and be driven by your values and softer skills to succeed. Continuously seek to see the wider perspective, seek out opportunities and take them, learn new things, build your network of contacts and seek the views of experts. It is not possible to have subject expertise in every area, but it is critical to know people who know things. Surrounding yourself with smart people and a culture of transparency, trust and collaboration is critical.
Communication as a leader is mainly about listening. Communication is a critical skill. It is important to be able to effectively deliver to staff and the public (often difficult) messages with care, clarity and assurance. But it is also more than just delivering a message; I have always believed that communication is two-way, and far more important is really listening to staff, patients and communities. From the very beginning of my time as Chief Executive of HK HA, I set about visiting facilities and services, always ending a visit with a staff forum. I undertook over 400 staff forums in my time as Chief Executive. To me, these were opportunities to talk with staff about the work of HA, hear the things that concerned them and make changes that matter to them. In addition, I built up the patient voice within governance arrangements of both facilities and services.
Always support change. I would also say, “Don’t be afraid to change”. Change is a journey and takes time. Change will never be 100 per cent perfect right from the start. There is a trap that people rely on pilot sites for ‘proof of concept’; these are often driven by enthusiastic individuals and targeted resources, and they are not fully replicable across all services. Set the expectation that changes are iterative and can be modified, and empower people to own the changes to be sustainable.
Focus on continuously developing and retaining good staff. Nothing happens without the positive engagement of staff, listening to them, providing opportunities to develop themselves and rewarding outstanding performance. It is essential to keep staff motivated and working towards shared goals.
(Header photo of HK HA Building by Tksteven [CC BY-SA 2.5])