Libby Lee Ha-yun, chief executive of the Hospital Authority, is with us, and she is sharing with us her vision and strategies for sustaining our public hospitals for the next generation.
Check out the full transcript of TVB’s Straight Talk host Dr Eugene Chan Kin-keung's interview with Dr Libby Lee:
Chan: Good evening. I'm Eugene Chan, and welcome to Straight Talk. Our guest is Dr Libby Lee, the new chief executive of the Hospital Authority. Dr Lee previously served as the undersecretary for health, and before that, spent over a decade in senior roles at the Hospital Authority, including the director of Strategy and Planning. She is a trained anesthesiologist with a Master's in Public Health, and with this combination of frontline medical training and public health administrative experience, she now takes on the task of steering the Hospital Authority into its next chapter. Congratulations, Libby, and welcome to the show again!
Lee: Hi, Eugene!
Where we are now
Chan: Libby, you have just stepped into one of the most important leadership roles of Hong Kong's healthcare system, and you know Hong Kong public hospitals have been described as one of the very best ones in the world, delivering high-quality care, actually, at a very low cost to the patients. And I would say the pressures are mounting due to the ageing population, as well as, of course, limited resources. Maybe we can start to tell the viewers where we are at the moment. Maybe you can walk us through with the latest figures, say how many patients we are looking after, and what your manpower size is and such figures?
Lee: Okay. So, the Hospital Authority is established under the ordinance – the Hospital Authority Ordinance. This is a statutory body. We are in charge of taking care of the patients within the public hospital system, including the clinics, I mean the outpatient clinics, and also inpatients. At the moment, we actually are serving the population and giving around 8.8 bed days per year, and then we also give like 8.7 million specialty outpatient clinic attendances per year. And in our primary healthcare, we are providing around 6.3 million attendances for the general outpatient clinic. So, I would say that in the whole Hong Kong medical healthcare system, the public system actually contributes around 80 percent of inpatient services and around 30 percent of the outpatient services. So, we will be, we are actually, key stakeholders in the whole healthcare system. And I must say that in terms of health, Hong Kong is actually doing very, very, very, very well. For example, we have the lowest, you know, we have the highest life expectancy rate in the whole world. And then we have the lowest maternity mortality rate, the lowest infant mortality rate, but only spending 9.1 percent of GDP. So, we are a very efficient system with good health outcomes.
Chan: Right, Libby. I know that apart from the obvious hospital services, the community enjoyed, you also have very important services in A&E, accident and emergency, special clinic, and also community outreach. Just now, when you said efficient, one must say that you just mentioned the average length of stay for a patient. So, how do the latest statistics that you just mentioned tell us how quickly the patients are going through our system? Because there are some acute cases, and also convalescent care.
Lee: All right, all right. I'll just maybe describe a bit of our services. Including inpatient services, we have acute inpatient services and convalescent and rehabilitation inpatient services. So, the average length of stay, if a patient comes through our system, they probably will stay in our hospital system for like six days, and then they will be discharged home, supported by our outpatient clinics, as well as some community services. For example, community nurse services, if they have wound dressing that kind of needs. And then, yes, our attendance at A&E (Accident and Emergency) is around 2 million per year. That means 2 million people attend A&E within a year. And some of them will be admitted into the hospital system, some will be followed in outpatient, some may be fit enough to be discharged from the A&E. So, this is the way that we actually provide our services in the healthcare system. The entry point will be the A&E, our patient clinic, stay in the hospital, be discharged back to the community and supported by our community care. And also, we collaborate very well with the Primary Healthcare Commission so that we are actually in the development of ... in the further development of our primary health care in the community.
Chan: Just now, you actually stated that we have a very efficient medical system compared to, I'm sure, other parts of the world. So, what are the areas that you think we excel in compared to other countries?
Lee: I guess the strongest point of our system is actually for the public health services system, we are united under one roof. That means, you know, in terms of finding drugs and equipment, we have different advantages from central procurement, so that we are more competitive in the market to bring down the cost. So, that's why it's one of the key factors to make us more efficient. Another thing is, actually, we are the main background, or the soil, to train our professionals. When the doctors graduate, when the nurses graduate, they would get into the training post in our system, in the public hospital system, and get trained and specialize. This is very efficient because they can rotate to different streams. They can broaden their horizon, and then they are very effective because it's standardized, our training program, so that they can get the fellowship, you know, in the shortest period of time. I guess this is the way that while we have advantages against other countries because our systems are over there in place and we provide opportunities while manpower to be trained up as a really professional and specialist.
Chan: Right. I think so far, we've been saying some very good points about the system. But how about if you look at the sheer volume of people in Hong Kong? Is the manpower under your team adequate, or are we still understaffed?
Lee: I must say that we are running a very efficient system. That means, to a certain extent, we will get better, actually even better, if we have more manpower. When you look at, for example, just use doctor as an example, when we look at the doctor per population, we are almost the lowest among Asian countries, running 2.3 per thousand population. So, there is room for improvements. That's why there are lots of policy in recruiting more students, overseas as well as we are talking about, with the government is thinking about opening a third medical school in order to beef up their manpower. So, this is one of the issues, manpower, more particularly for the nurses. Nurses are more difficult to get because they're really, you know … around now we've got 30,000 nurses in the system, but we have quite a number of shortfalls, and a lot of nurses being trained as nurses may not end up being a nurses in the system. So, that's why we also follow up on a policy, recruiting more nurses non-locally to come here, as well as increasing the number of training posts.
Chan: Right, I'm going to ask you later on about the attrition rate of our team.
Lee: Good.
Chan: One area that I'm sure the viewers will think of is the Hospital Authority, when the HA is on the news. Unfortunately, sometimes when some of these serious events are happening in Hong Kong, some unfortunate medical incidents. But after I've done some homework, because compared to international standards, Hong Kong is only 0.32 out of 100,000 people, compared to 0.43 in the US and even 0.57 in the UK. Does that mean that people in Hong Kong are getting … or the public is expecting more from HA compared to the rest of the world? Or do you think it’s a fair comment by the public when they sometimes say that the Hospital Authority does have this serious event that I'm sure none of us wanted? How would you respond to my statement?
Lee: I guess in any healthcare system, it is impossible to say that there won't be any medical incidents, what we call about Sentinel Events or medical incidents. Because in our industry, basically, it's human to human. Human touch is actually such a major component. And by being human, we cannot be assured that we are 100 percent safe proof. So, I guess it is impossible to say a medical system without medical incidents. But the point is how to reduce it and how we learn from these medical incidents. So, when we compare with overseas countries, we are well aware that there are differences between systems. For example, the speak-up culture, the trend of bringing up incidents, may not be the same among different systems. So, even if we look at a number, I would prefer comparing the number with our past trend. But to be honest, our numbers are not huge in that sense, but no medical incident is desirable. So, we can understand that the public have expectations of us and also patients suffering in terms of medical incidents. So, our key is actually not focusing on a number, but on how to improve from those medical incidents.
Pressures and challenges
Chan: Right, Libby. Let me come back to the point I just brought up earlier about staffing, which is always a hot topic. The attrition numbers I've looked up are about 5 percent annual attrition rate for doctors and a bit higher, like 7 percent, for the nurses. That means over 340 doctors or 1,800 nurses left the service last year. Why are we losing so many dedicated professionals?
Lee: Oh, there are two components for that. The first one is normal retirement. Of course, you know, we have baby bloomers, and this time in certain years, they probably will retire from the system. And you think about it, we got 7,700 doctors. So, a 5 percent attrition rate is quite a normal turnover rate for professionals. And some will leave the public system to the private. Some may, you know, migrate to other countries, and some retire. So, I guess 5 percent is almost, you know, what we're looking at. But in previous years, we could go up to 8 percent or 9 percent. So, I guess what we should prepare is a healthy turnover for each professional. Look at nurses. We have 30,000 nurses in the system. So, you're talking about 6.7 percent, 1,800. It's not a lot, but you know, it's a normal turnover. But what we want to keep in our system is actually the experience that they have. You know, when you know the experienced staff leave the system, some newcomers replace them. The newcomers may be less experienced. So, what we are looking at is how you, you know, retain this experience in the system for better patient care.
Chan: Right, maybe one more area I’d like to explore before the break is burnout. I'm sure a lot of people who say there are, even you have their numbers, they must be motivated. I'm sure you went through the system over the last few decades; you know what the frustrations are. How do you minimize burnout and make sure they are feeling very welcome or feeling fulfilled at a job? What would you do about that?
Lee: That’s a very good question, Eugene – burnout. In the healthcare profession, burnout is actually quite a severe problem, not only in Hong Kong, internationally, because for self-expectation, as well as public expectation. Staff usually get overwhelmed because of the expectation and also the workload. I guess we need to use some smart method to reduce the workload. And also we need some refresher, energizer, to make staff more eager to stay in the system. So, I would say the way that we, you know, we engage our staff in the system in providing service to patients can change a bit so that they feel more energy when they provide service to the patient. We can talk about it later on how we actually energize them.
Chan: Right, Libby. Time for a quick break now, but we will come back with more straight talk.
Chan: Thank you for staying with us. Dr Libby Lee, the newly-appointed chief executive of the Hospital Authority, is with us, and she is sharing with us her vision and strategies for sustaining our public hospitals for the next generation.
Pressures and challenges
Chan: Libby, as the title suggests, next generation, meaning that, as a public person, I think the HA is doing a great job, but how do we sustain this for the next generation? And maybe we can just go on a bit more on the staff burnout rate we just touched on in the first half. I have read your interviews recently, and you have spoken passionately about bringing warmth and a speak-up culture to the Hospital Authority. You have said if you are good to staff, they will they will be good to the patients. Can you sort of elaborate a bit more on that? And what I mean is, what tangible changes are you making to improve the working culture, so that the staff will actually feel valued and stay on?
Lee: Okay. Staff is not only doing the routine daily work, operations. I think staff have a lot to offer, and they would like to give out more apart from the normal daily operations. For example, what they aspire to do during the daily work, you know the staff who stay in the public hospital system really have a passion and also a vision they want to achieve, because there are so many ways to have a more comfortable life. And they choose to stay in the Hospital Authority, which provides so many, you know, day-in and day-out services. They really want to achieve something, like service model change, or for example, using new adopted technology in the system, so as to make the whole system a better system for the patients, and also for the staff. So, in the coming years, I would like to engage them a bit more. I think this is engagement, staff engagement is the key medicine to take away the burnout. Apart from reducing the workload, how to engage them to have a bigger contribution, a higher level of involvement in the whole system, I think that will be actually improve the staff morale, and make their passion become an action, really help them to stay, to keep the energy in doing the work. So, warmth is actually something like improving staff communications, more staff engagement during policy-making, and service model changes. And then let them lead the way, I think they could offer a lot more than they want to offer. So, this is the way that I think that is the future because I have been on the frontline many years ago, I do think that we have good ideas, I have good ideas. If there is a way that I can turn these good ideas into action, I will be very happy to stay in the system and serve.
Chan: Right. I want to ask you about the speak-up culture. What do you mean? You mean the nurses or the junior doctors will be going directly to you? Or they go through the system to the seniors?
Lee: I think the speak-up culture is a culture that you do not, you are not afraid to speak out your mind. And if you see something wrong or if you see someone's behavior is not right, you are not afraid to tell him or tell the senior or tell the colleagues that we actually have a way to improve that. I think first of all, you need to feel safe before you can do this. Even in a meeting, people dare not to express their opinion because they think that is not safe. If I say something stupid, then someone will laugh at me. I guess speak-up culture is a morale or is a culture that staff feel safe to express their opinion without any consequences. And this is something that I want we have because brilliant ideas come out like this.
Chan: I like what you said, without any consequences, because a lot of professionals, even myself, you have to be pretty confident to make a comment. Sometimes you might think it might show your actual inadequacy. But hopefully things will improve under your leadership. Another area that we want to talk about is recruiting non-locally trained doctors and nurses. How is that impacting the frontline? I mean has there been improvement or is there still sort of a grinding period?
Lee: I will tend to think that … currently we have like 300 something doctors in our system already. We are now actually recruiting more non-local nurses, but the competition is really keen. I tend to think that non-local doctors is a sort of manpower can actually serve in our system. And when they join the HA, they will be part of our staff. I would not like to distinguish them from non-local and local; they are our staff. But in fact, the way that they are trained, like overseas, really have some differences from our locally-trained people. And there will be some, you know, reaction, chemical reaction between these two cultures of being brought up. So, this is a very good thing because in my old days, I did anesthesia, half of my department were actually foreigners, not local people. And then they bring good ideas actually, when these two cultures, I won’t say “clash,” react together, and it can really give a positive outcome. So, even when the manpower issue has been solved, I still see the merit in bringing non-local people back to the system.
Chan: Libby, another area, I mean, there are a lot of things I want to ask you today. Another area you have talked about is actually the possibility of extending operating hours at the general outpatient clinics, something very new to the Hong Kong public. I think you want to work until like 10 o’clock in the evening. So, when is it going to happen? And do we have enough resources for it?
Lee: Okay, so we are exploring it. We hope that after all the exploration, we can bring it into real action sooner. The sooner the better. The idea is actually that we want to run a very smart system. So, you know the whole day long, basically we can analyze at what time people will come to use your general outpatient clinic. Maybe you know, some hours are more patients, some hours are fewer patients. So, if we extend the operating hours, likely the people just finished work, they would like to see a doctor, they have a chance to see it, and then we can actually tailor make the quota according to the needs, the service needs. So, I would think that is a smarter way of operation for the general outpatient. So, will that … if we have enough resources to do this, resources in terms of money, people, and the facilities. Currently, the facilities are adequate because we have just opened them longer. But in the near future, we will need more clinics. Currently, we actually are not able to fulfill all the needs of the Hong Kong people, for the general public outpatients. So, facilities are one issue. For manpower, we also have the need to train up more family doctors because Hong Kong really needs a robust primary healthcare system.
Chan: Right. Just now you just mentioned smart technology as well. And I know that in Tseung Kwan O Hospital, you have part of a team, a sort of one-stop digital kiosk that patients don’t have to queue up for everything, they just go there to arrange like seeing the doctor, collecting the medicine, or even booking the follow-up, etc. So, how quickly can you roll up such initiatives and whether, I mean to other clusters, so that it sort of genuinely reduces waiting time?
Lee: Okay. Basically, we have two pilots at the current moment – one pilot is the Tseung Kwan O and the other is the Hong Kong Eye Hospital. Hong Kong Eye Hospital is not only using a kiosk to do that, they try to do it in HA Go. So, in your iPhone or in your cellphone, smartphone, basically, you can use our HA Go app, you can actually, when you come to our clinic and see the doctor, they will show you the roadmap where to see, where to go. And then we hopefully can enhance this app, so that later on you can book your, after consultation, next follow-up appointment, the next blood taking appointment. We are working on that. I hope that we can do that in a year of time. For this system, currently not perfect, but we also want to try it out in all eye departments of our system. So hopefully within this year, we can actually have this system implemented in all eye departments. For the Tseung Kwan O one, it is basically for special outpatient. We are actually streamlining, improving the system and we are testing it out within this year. And different clinics are trying it out, see whether we can further improve it, and make it more tailor made for each clinic. So, there is a road map for all of these.
Sustainability and affordability
Chan: Right. As you are telling us about the good things the HA is doing, it quickly something came to my mind. Will you be your own victim of your own successes? Because there will be more people coming, and then it is like a snowball, it is going to be more and more. As you know, we have an ageing population, costs are rising. And I have checked the HA budget has grown significantly from HK$90 billion in 2022-2023, to the proposed HK$107 billion in 2025-2026. Do you think the current funding model is sustainable or will we need to rethink how the whole healthcare financed? That is the title of the show today.
Lee: I guess what I hope is actually sustainability is not a question to ask, we have to work towards the sustainability. So, when I go back to the HA, I look into resources, the expenditure, that kind of stuff. Strictly speaking, we break it down to two components. The one component is actually for population ageing, demographic changes, chronic disease, incidents. The group is steadily around 3 percent every year. So, this part actually can be handled by primary healthcare, shifting the service model. But what could not be really handled is about the increase in service cost, that is the technology adoption. We see the rate is actually exponentially increasing. So, I guess smart adoption of technology is an essential way to actually control the budget, and also improve cost effectiveness, and then make it more sustainable. What to adopt and what not to adopt is a key.
Chan: Right. Libby, there are also the upcoming three reforms, it will be another hot topic; the public will be engaging. You have stated that is based on co-payment by those who can afford it and co-payment by those who may not be able to afford it at all. So, how are you going to do that, because payment is a very sensitive issue, especially in the current economy, and the government is trying to cut down expenditure? How will you answer that question?
Lee: “Fees and charges changes reform” is a reform to shift the resources from, you know, the less needy to the most needed patients. So, we actually have waiver systems to make people who cannot afford the system, they have ways to help them. And when we get back the resources from a bit more co-pay from those who could afford or for those who have a lighter disease or less serious disease, we can basically have these resources redistributed to cover those who are really needy. So, it is a redistribution of resources in fact.
Chan: Right. So, you are confident that we can afford this healthcare system in the future, despite it is 9 percent of our GDP?
Lee: It is not a confidence level; it is a must-do thing. So, we must make it a sustainable system for the Hong Kong people.
Chan: Right. Thank you, Libby, thank you for sharing your strategies and your insights.
Hong Kong's public hospitals serve millions every year, and remain the backbone of our healthcare. Sustaining them for the next generation is crucial, and will hinge on recruiting talent, implementing smart financial reforms, and then embracing a new model of care. Thank you for joining us on Straight Talk, and have a good evening.
