LegCo Paper No. CB(2) 1058/96-97
[These minutes have been seen by the Administration]
LegCo Panel on Health Services
Minutes of Meeting held on Monday, 9 December 1996 at 8:30 a.m. in Conference Room B of the Legislative Council Building
Members present :
Hon Michael HO Mun-ka (Chairman)Members absent :
Dr Hon Edward LEONG Che-hung, OBE, JP (Deputy Chairman)
Dr Hon HUANG Chen-ya, MBE
Hon Howard YOUNG, JP
Dr Hon LAW Chi-kwong
Dr Hon YEUNG Sum*Public officers attending :
Clerk in attendance :
Hon CHAN Yuen-han*
Hon MOK Ying-fan*
Staff in attendance :
- Ms Doris CHAN
- Chief Assistant Secretary (2)4
- Miss Joanne MAK
- Senior Assistant Secretary (2)4
1. Members agreed to follow up on private practice of university medical consultants and specialists, which was tentatively scheduled for further discussion at the meeting in February 1997 and to remind the Administration to report the results of its investigations to the Panel. Meanwhile, Dr LEONG Che-hung would provide any additional information he had to facilitate the discussion.
2. Members discussed and agreed on the scope of discussion in respect of the monitoring of clinical services in public hospitals and control of Chinese proprietary medicine.
3. Members considered that the suggestion of the Administration to postpone the manpower assessment for Siu Lam Psychiatric Centre (SLPC) to a later stage was unacceptable.
4. Members agreed to discuss the following at the next meeting -
(a) Manpower shortage of nurses;
(b) Registration of dental surgery assistants, dental technicians, dental therapists and dental hygienists; and
(c) Review of the health care system
5. Pending the investigation report on the waste of blood at the blood bank of the Red Cross, the date for discussion on this matter would be decided at a later date.
I. Confirmation of minutes of meetings held on 7 and 14 October 1996 and matters arising
(LegCo Papers Nos. CB(2) 602/96-97 and 603/96-97)
6. The minutes of meetings held on 7 and 14 October 1996 were confirmed.
Matters for discussion at the next meeting on 13 January 1997
7. The Chairman informed the Administration of the discussion items for the next meeting, and requested the Administration to make available the periodic progress report on the review of health care system the earliest possible. The Administration agreed to consider this request.
8. The Chairman noted that objections had been raised by some parties to the proposed registration of dental surgery assistants, dental technicians, dental therapists and dental hygienists. The Administration reported that they had referred the matter to the Dental Subcommittee of the Health and Medical Development Advisory Committee to review whether or not the proposed registration system made a few years ago was applicable in the dental sector now. The Dental Subcommittee would compile a preliminary report on the review in January 1997. The Administration would confirm if the report would be ready by the next meeting scheduled for 13 January 1997. The Administration told that the relevant legislation was yet to be drafted.
(Post meeting note: The Administration clarified that the Dental Subcommittee of the Health and Medical Development Advisory Committee would set up a Working Group, comprising representatives of the professions, to study the matter, in January 1997. The Working Group was expected to report in six months time.)
II. Manpower problem of Siu Lam Psychiatric Centre
(LegCo Papers Nos. CB(2) 611/96-97 (01) and (03))
9. The Chairman highlighted that the matter had been discussed for over nine months; and, at the meeting held on 18 June 1996, the Panel had clearly conveyed their dissatisfaction with the manpower review conducted by the Hospital Authority (HA), which only covered the staff mix between Registered Nurse (RN) and Enrolled Nurse (EN). Moreover, the review did not address the existing problems pertaining to the night nursing situation at SLPC -
(a) No nurses on duty in the wards at night leaving the inmates locked up unattended; and
(b) the two Night Orderly Officers (NOO), who were the only staff with the professional nursing qualifications, had to patrol around the whole premises of SLPC; thus leaving them with no spare capacity to attend to the inmates or to assess their conditions. In accordance with the Standing Orders of the Correctional Services Department (CSD), one of the NOOs was not even allowed to enter the wards.
The Chairman recalled that it was clearly recorded in the minutes of an earlier meeting that the Health and Welfare Branch (HWB) and the Security Branch (SB) had agreed to conduct a manpower assessment of SLPC from a medical point of view. The Chairman requested the Administration to explain why they had now changed their stance and instead proposed that the assessment to be done at a later stage.
10. In response, the Administration first outlined the improvement measures taken to alleviate the manpower problem of SLPC since June 1996 and assured members that with the provision of professional training to the staff and creation of additional posts, the standard of psychiatric service would be considerably enhanced. As it was the transitional period for SLPC during which improvements would be made to the level of psychiatric nursing service, the Administration considered it more appropriate to review the manpower requirement after complete implementation of the recommendations with their full effects shown.
11. The Administration further explained that there would be the following technical problems to conduct the manpower assessment at the present stage -
(a) The existing level of nursing service at SLPC could not be used as the point of reference to project the future manpower requirement. Due to staff shortage problem, some posts required to be filled by staff with formal nursing training were currently filled by staff without such qualifications, leading to a sub-optimal level of care for the inmates at this stage; and
(b) since SLPC was both a psychiatric and penal institution, the Administration could not assess the manpower requirement for SLPC simply by making reference to a conventional hospital.
In view of the foregoing, HWB and SB had mutually agreed that a manpower assessment should not be conducted at the present stage.
12. Members appreciated the unique nature of SLPC; but opined that so long as the inmates were considered as "patients" and their needs for psychiatric service recognised, the Administration was obliged to provide the necessary nursing manpower to deliver an acceptable level of service. On this basis, it was necessary for the Administration to develop a benchmark for the nursing staff level taking into consideration the number of patients to be served. Members opined that the improvements being made by the Administration to the manpower and staff training for SLPC could be done in parallel. On top of that, members still needed to know the ultimate target of manpower that the Administration wanted to achieve so that they could assess concretely whether the improvements brought about were on target or not. Members considered that there was no point in waiting for completion of the improvements when they did not know what the ultimate targets were. They considered that the response of the Administration was totally unable to meet their expectation.
13. The Administration explained that they did have an explicit target to achieve which was to fill the 97 front-line posts all by staff with nursing qualifications; though they understood that members might take a different view. At present, efforts were being focused on the strengthening of nursing support in priority areas such as night-time duties and the Admission Ward where patients required intensive psychiatric care and observation.
14. Being questioned about the role of HWB in the preparation of the SBs paper, the Deputy Secretary for Health and Welfare Branch informed the Panel that they had collaborated with SB in working out the paper and played a supportive role in implementing any manpower review for SLPC.
15. The Chairman asked HWB whether the situation as detailed in para. 11 (a) and (b) was acceptable from a medical point of view, bearing in mind that SLPC was supposedly a therapeutic institution without which, the inmates would have been sent to the Castle Peak Hospital to receive medical consultation and psychiatric care by nurses.
16. The Administration considered that, in view of the unique nature and physical layout of SLPC, it was not appropriate to compare it directly with any conventional hospitals.
17. Dr LAW Chi-kwong opined that, contrary to what the Administration said, it was now the best timing to do the manpower review. With the implementation of the improvement measures at SLPC, much useful and relevant information had been gathered and the deployment of staff was now fluid with the injection of manpower resources. Dr LAW proposed the Administration first to assess the basic manpower requirement for SLPC by assuming that it was only a general hospital; and re-assess it by assuming that SLPC was purely a correctional services institution. The total number of staff with nursing qualifications could then be derived from the findings of the two assessments and then modified taking into account how the staff were actually deployed in performing both nursing and custodial duties. He considered that as the Administration was now looking into the duties of the staff and evaluating their proportion of nursing and security services, it was the best opportunity for the Administration to do the manpower assessment and re-distribute the staffs duties where appropriate. Dr LAW explained that a manpower assessment was necessary to compare the actual level with the level in demand in order to see how wide the gap was.
18. The Chairman recalled that it was already examined and also concluded at earlier meetings that the number of the 97 staff was not adequate for deployment at SLPC if the Administration wanted to have at least one nurse for each ward on a 24-hour basis, not even to mention that there were also correctional services duties to be performed which required further manpower. He asked the Administration to devise a basic manpower requirement by projecting the minimum number of nurses required for each ward, for 24 hours a day. In deciding on this minimum number of nurses required for each ward, the Administration should take into account some emergent and demanding duties (such as compiling the Remand Order reports) which had to be performed by the nurses. Given the present unsatisfactory manpower level with no nurses to attend the inmates at night, the Chairman queried how the Remand Order reports were written since they required nurses to observe and monitor closely the conditions of the inmates throughout the day.
19. In reply, the Administration said that after filling the 97 front-line posts by staff who had acquired the professional training, there would be qualified nurses in each ward at night. In the interim period, they had deployed some newly trained ENs at the Acute Disturbance Units to perform the night shift duties. The Chairman considered that this represented deterioration in the standard of service as compared with the past where the patients, after being remanded into the custody of the Castle Peak Hospital, were written reports by RNs instead of ENs.
20. The Chairman requested the Administration to take into account the types of wards and patients at SLPC, and then decide on the required number of RNs and ENs for each of the wards in order to calculate the total manpower requirement, with allowances made for leave relief staff. Members considered that the Administration should not first assume that 97 nurses were adequate for providing the basic psychiatric service at SLPC.
21. In response, the Administration pointed out that, during the manpower assessment exercise done by the CSD, they had already taken into account the manpower need for the wards; although the ratio of RNs and ENs was not specified then. However, given the established practice of the CSD to fill their Officer rank by RNs and Assistant Officer rank by ENs, it was estimated that the 97 nurses would comprise 34 RNs and 63 ENs. Moreover, the manpower assessment compiled then had specified the basic staffing requirement for the wards on day shifts and night shifts, and stipulated that at least one, or even two ENs in some cases, must be provided for the wards at night. However, the Chairman pointed out that the Panels concern was the unsatisfactory level of psychiatric service being provided at SLPC now; and the lack of information on the amount of workload of the nurses who had to handle both psychiatric and custodial duties even including the manning of the watch towers and other facilities. The Assistant Commissioner of Correctional Services (Operations) (AC(CSD)) clarified that normally, they would not deploy a staff who had been trained in nursing care to man the watch tower. Any such deployment was exceptional due to operational reasons. In response to the statement of AC(CSD), the Chairman pointed out that such arrangements were quite frequent and informed the meeting that the staff whom AC(CSD) had met at the watch tower during his last night-visit to SLPC was a qualified EN. The Chairman requested and the Administration undertook to look into frequency of such deployment.
22. Members requested the Administration to provide figures specifically on -
(a) the manpower requirement for SLPC assuming that it was purely a therapeutic institution;
(b) the manpower requirement if SLPC was purely a penal institution; and
(c) the actual time spent by the SPLC staff on custodial and nursing duties.
The result of (c) would be used to modify the total of (a) and (b) in determining the actual manpower requirement.
23. Representatives of the Administration expressed their reservation about the value of this paper exercise as it was impractical to assess the manpower requirement of SLPC by assuming that it was like the other conventional hospitals. The Administration proposed to put on hold the manpower assessment and to make periodic progress report to the Panel on the implementation of the improvement measures and their effect. Members did not accept the proposal and pointed out that the time spent in the past year in urging the Administration review the manpower requirement of SLPC would be wasted if the Administration went back on what had been mutually agreed by the Panel and the Administration in June 1996.
24. The Administration reiterated that when they proposed in 1994 to have 97 nurses, they had assessed the actual need for nursing manpower. For example, they had also taken into consideration the need for night shift nurses, hence recommending the creation of four additional posts at officer rank. They repeated that any assessment might not be suitable for use in SLPC in the long term if it was based on the current mode of operation of SLPC which would undergo rapid changes in the coming months.
25. Members were very dissatisfied with the Administrations reply. They opined that the Administration was adopting a delaying tactic on this matter and insisted that the Administration should conduct the requested manpower assessment.
26. The Administration requested more time be given for them to explore alternative ways to work out some figures leading to more fruitful discussion on the subject. Should the Administration decide to conduct the requested manpower assessment, they had to sort out the approach for the exercise. However, the Chairman considered the Administrations reply a regression as compared with the last time; and restated the Panels request for an assessment on the basic manpower requirement for ENs and RNs for SLPC and details of their deployment. The Administration undertook to give further consideration to how best to carry out an assessment exercise and would revert to members before conducting any review. The Chairman directed that this item be followed up at the next meeting to be held on 13 January 1997.
III. Monitoring of the quality of clinical services in public hospitals
(LegCo Paper No. CB(2) 611/96-97(02) )
27. The Chairman remarked that the discussion on this item should focus on the mechanisms of HA for monitoring the quality of clinical services in hospitals. It would not go into the incidents recently reported by the media alleging of negligence of the clinicians and other health personnel in public hospitals.
28. The Deputy Director of HA (DDHA) assured that HA had been seriously investigating and following up every complaint with a view to improving the quality of the service. He pointed out that the formulation of performance standards, among others, was an important step in establishing the monitoring mechanisms in public hospitals. He further highlighted the concept of clinical audit - specialists were appointed to audit clinicians of their specialty to see if the latter had strictly followed the relevant patients management protocols, and advised them to make improvements as appropriate. Special framework had also been set up to monitor and review more serious cases relating to, for example, medication incidents.
29. Members enquired whether the recent series of incidents reported by the media represented a sudden surge in the number of this kind of accidents in hospitals or they were the tip of the iceberg. They further asked if the situation was a reflection on low morale of the HA staff. In response, DDHA said HA was greatly concerned about recent series of accidents; but it was not appropriate for him to draw any conclusions now on the causes of these accidents. He assured that HA understood and well accepted the rising expectations of the public on the standard of medical service. Different monitoring mechanisms had already been established over the past few years, like the one set up to monitor the mortality rate of infants, to assess the standard of service rendered. In addition, HA had been encouraging staff to report every single case where inconsistency with the operational procedures was found. All these reported cases were thoroughly reviewed to identify areas for improvement. At the request of members, HA would provide statistical figures on cases involving birth asphyxia over at least the past three years for members reference.
30. A few members pointed out that symptoms of slight deprivation of oxygen supply during delivery might not appear until the affected child had grown to adulthood. DDHA agreed and said that the hidden long-term effect of the problems encountered during delivery had been of growing concern in the western world. However, in respect of those cases affecting mental ability, it would be difficult to determine and substantiate by evidence.
31. Members were concerned whether there were clear clinical guidelines laid down and records of failures of the clinicians in following these guidelines. DDHA confirmed that clinical procedures had been laid down for treatment of many types of diseases and HA was committed to improving the situation as far as possible. There were also clear clinical guidelines drawn up by relevant specialty clinicians for matters like procedures of issuing medicine and handling of birth delivery. In addition, clinical audits had been conducted for cases involving death of a child within one year after birth. These cases were examined in great detail by specialists from different hospitals to see any steps in the delivery had gone wrong. He stressed that clinical audits examined not only the results of the treatment but every step taken in the course of the process to identify any room for improvement. Members requested and DDHA agreed to provide statistics on emergency caesarean delivery conducted. In response to a question, he explained that the need for caesarean delivery was based on the obstetricians decision. In some cases which should be by natural delivery, it was found during the process that due to insufficient strength or other reasons, emergency caesarean delivery was required.
32. Members enquired if figures of caesarean delivery were available to see if there was a surge in the number of such delivery due to the recent incidents reported by the media. DDHA agreed to provide such figures.
33. At the request of the chairman, DDHA agreed to quote real cases to illustrate the operation of their monitoring mechanisms and the clinical audits established for various systems.
34. A member expressed his concern about the delay in transmission of medical records between hospitals. He queried why there were still such complaints after considerable resources had been devoted to improving the information technology of HA since its establishment six years ago.
35. DDHA explained that HA had been targetting this problem on two fronts: reducing the rate of record loss and shortening the access time. He pointed out that even with computerization, medical record management was a very difficult issue not only in Hong Kong but in all hospitals over the world. He said much improvement had actually been made since the take-over by HA. Clinicians were also establishing the habit of returning the records to the registry after use. He quoted the case of the Prince of Wales Hospital where the rate of loss had now been reduced to below 1%. He assured that HA would continue to improve the system to ensure proper and efficient custody and retrieval of medical records.
36. DDHA also informed members that computerisation was being introduced to the clinical system. For example, after diagnosis, the clinicians could send the prescriptions to the dispenser on line right away and thus shortening the waiting time for patients.
37. Members enquired on the provision of summaries of patients medical records, which were very useful to allow quick reference of the health conditions of patients during treatment. DDHA informed members that these summaries had been made available at all the Outpatient Departments (OPDs) and the Emergency Units of the major hospitals by softcopies or hardcopies. In the transfer of a patient to another hospital, the administration of the hospital would ensure that the summary of the patient should reach the receiving hospital in the first instance.
38. DDHA also reported that HA was implementing some pilot schemes to transmit X-ray and other pathological reports by computer to OPDs and between some hospitals. The scheme would be gradually extended to all hospitals.
39. The Chairman enquired what channels were available to the public if they were not satisfied with the treatment or experienced problems after the treatment. DDHA explained that the effect of a treatment might not be observable or known even long after the consultation and that specialists had been appointed to devise some objective indicators in this regard. As requested by members, HA would provide information on their progress of work.
40. As regards lodging of complaints, DDHA answered that patients could lodge his complaints either with the Patients Relations Officer at the hospitals concerned or the HA Public Complaints Committee with lay representatives. The committee could also appoint specialists from another hospital to examine the complaint.
41. DDHA further reported that with the Personal Data (Privacy) Ordinance coming into effect on 20 December 1996, HA was obliged to provide patients with copies of their medical records upon request. The Ordinance stipulated that the requested information should be provided within 40 days after an application was received. DDHA said that HA had already devised some internal guidelines on how to comply with the Ordinance and agreed to provide them for members information
IV. Control of Chinese proprietary medicine
(LegCo Paper No. CB(2) 611/96-97 (04) )
42. Members were concerned that there was a generally greater risk with the intake of Chinese proprietary medicine, partly because its control was less stringent than western medicine. Unlike the way in handling western medicine, the Department of Health (DH), because of lack of information, did not collect samples from every new type of imported Chinese proprietary medicine to test if the ingredients were same as those listed on the label. Another problem with Chinese proprietary medicine was that medicine with the same brand name could be manufactured in different regions of China with varied standards of quality. Therefore, it was inadequate to test only one sample for one brand name. Although the Preparatory Committee on Chinese Medicine (PCCM) had been set up to explore some controlling measures on the subject, members would like to know whether there were any interim measures to ensure the safety of Chinese proprietary medicine.
43. The Administration informed members of the following measures being taken to tighten up the control on such medicine -
(a) a computerised data base was being developed on the types of Chinese proprietary medicine imported to Hong Kong;
(b) DH was reviewing and streamlining the sampling procedures with the Government Laboratory with a view to increasing the number of samples to be tested;
(c) DH was strengthening its contact with the Chinese authorities to exchange information and monitor the import of Chinese proprietary medicine; and
(d) the PCCM would issue a set of guidelines to the wholesalers, retailers, importers and manufacturers of Chinese proprietary medicine.
In addition, the PCCM would submit a report recommending a legislative framework for the regulation of traditional Chinese medicine by early 1997.
44. The Administration explained that under the Import & Export Ordinance, an import licence would be issued by the Trade Department if the medicine contained no western drug ingredients. Registration was required if there were such ingredients found and then samples of the medicine would be collected for testing. On the basis of the estimate that there were about 3000 items of proprietary Chinese medicines in the market, about two-thirds had been collected and analysed. Only a very little portion of it was found to contain heavy metal and such medicine was mainly for external use. The PCCM had considered the need to have new legislation for the control of Chinese proprietary medicine, and would discuss the standards required for Chinese proprietary medicine.
45. As regards locally manufactured Chinese proprietary medicine, the PCCM would issue a set of guidelines for the reference of the people engaged in the trade of Chinese medicine. Then there would be discussions and consultation with the trade on the way forward for importation, production and sale of Chinese medicine.
46. At the suggestion of members, the Administration agreed to strengthen the function of the data base in tracing which type of Chinese proprietary medicine was for the first time imported into Hong Kong and to ensure that every newly imported Chinese proprietary medicine had to be tested when it was first imported to Hong Kong. The Chairman suggested that the Administration should consider passing on the charge of such analyses to the importers or manufactures concerned or requiring them to provide certifications from local laboratories. As to the requirement for certification, there might not be enough laboratories for the purpose.
47. The Administrations pointed out that in considering the origin and the trade of such medicine, it was necessary to fit in with Chinas policy on such matters. After some discussion, members and the Administration agreed that the importer of Chinese proprietary medicine should be responsible for proving that the medicine did not contain western drug ingredient when there were adequate laboratory facilities in the private sector to support the activity. If implemented, details of the policy could be laid down in legislation and the cost should be absorbed by the importer himself.
Legislative Council Secretariat
21 January 1997
Last Updated on 19 August 1998