20 October 2016
Health Secretary Dr. Ko Wing-man (inset) envisions a voluntary health insurance scheme before the required legislation is completed. Photos: HKEJ, internet
Health Secretary Dr. Ko Wing-man (inset) envisions a voluntary health insurance scheme before the required legislation is completed. Photos: HKEJ, internet

What to do with too many doctors who make too many mistakes

Health Secretary Dr. Ko Wing-man says the government will try to introduce a voluntary health insurance scheme as early as possible through an agreement with the insurance industry before the required legislation is completed.

Meanwhile, there has been no mention of the results of a consultation on the regulation of private healthcare facilities.

It is very likely that, if the scheme is implemented early as planned, the number of patients treated in private hospitals will substantially increase while these hospitals will continue to operate under the existing regulatory framework.

This raises the issue of whether this framework is adequate in ensuring safe hospital care for patients.

This issue must be taken seriously if we are serious about the safety of hospital care.

Evidence from research studies worldwide conducted over the past couple of decades consistently indicates that a substantial number of patients suffer treatment-caused injuries resulting from preventable medical errors while in hospital.

In the United States, the renowned Harvard Medical Practice Study found that in 1984 in New York State, treatment-caused injuries from preventable medical errors occurred in 2.2 percent of hospitalizations (equivalent to one in 47 hospital patients).

In Australia, a study commissioned by the Commonwealth Department of Human Services and Health found that the corresponding figure was 8.5 percent (one in 12 patients) in New South Wales and South Australia in 1992.

In New Zealand, 6.3 percent of hospital admissions (one in 15 patients) were associated with preventable medical errors in 1998.

In the Netherlands, the figure in 2004 was 4 percent (one in 25 patients).

These figures, however are only the tip of the iceberg.

Significantly, when the causes of errors were investigated, the studies found that the great majority of medical errors, ranging from 56 percent to 75 percent, were not the result of faulty care delivery systems but of individual physicians.

In addition, two recent studies found that a disproportionately large number of medical errors are in fact committed by a very small proportion of doctors in the medical workforce.

The first study, using data from the US National Practitioner Data Bank, a federal database of malpractice judgments in the country, found that between 1990 and 2010, about 2 percent of American doctors were responsible for 50 percent of the cases in which a patient was seriously and unnecessarily harmed when undergoing treatment.

The second study examined formal patient complaints filed against doctors with health service ombudsmen in Australia from 2000 to 2011.

Similar to the US study, it found that 3 percent of Australia’s medical workforce accounted for 50 percent of all complaints and 1 percent accounted for a quarter of all complaints.

In view of the Australian finding, New Zealand’s former Health and Disability commissioner said there is a need to focus on problem doctors if the quality of healthcare is to be improved.

In the wider context of policy response, a patient safety movement launched in the early 21st century in North America has arrived at the recognition that “the time has now come to design and evaluate systems that identify problematic [clinicians]”.

The researchers of the Australian patient complaints study recommended “immediate steps to improve, guide or constrain the care being provided by ‘high-risk’ practitioners”.

A retired US hospital chief of staff wrote in the medical journal, BMJ Quality and Safety, in 2014 that it is “likely that we could retire those [hardcore bad doctors] on a handsome stipend without increasing the cost of medicine”.

Unless there is strong reason to believe that the overseas research findings have no relevance to Hong Kong, it is imperative for hospitals to have systems in place that are capable of tracking and evaluating doctors’ performance effectively.

With regard to private hospitals, the regulatory framework is lagging.

The Hospital, Nursing Homes and Maternity Homes Registration Ordinance (Cap. 165) contains no explicit mechanisms for credentialing doctors and monitoring their performance.

The Code of Practice for Private Hospitals, Nursing Homes and Maternity Homes (Cap. 165) is non-statutory and its implementation is left to the hospitals themselves.

The effectiveness of the mechanisms is highly uncertain.

Meanwhile, the process for ensuring doctors’ competence as proposed in the recent consultation document on the regulation of private healthcare facilities is vague.

There is no mention of how much of the code will be adopted and made mandatory.

The document proposes only that “private hospitals should have a robust human resource policy so that staff members serving in hospitals could meet the benchmark desired and adopted by the hospitals concerned”.

What matter most, however, are the specific contents of the human resource and credentialing policies.

Much of it still a blank sheet. We think the code should be reviewed and made mandatory as a starting point.

There should be no question that a voluntary health insurance scheme should be introduced before a vigilant system is in place that can effectively monitor and evaluate the performance of medical practitioners in private hospitals.

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