Holistic approach required for city’s A&E services

Awell-functioning healthcare system is intricately linked to effective governance, as it signifies a government’s responsiveness to citizens’ needs, promotes social justice and equity, protects public health, enhances economic stability and productivity, fosters trust and confidence in governance, and requires efficient allocation of resources. In the Hong Kong context, there is currently a proposal to raise fees associated with the use of accident and emergency (A&E) services in public hospitals. The primary objective, as articulated by Professor Lo Chung-mau, secretary of health, is to address the issue of misuse and alleviate the strain on the public healthcare system. The proposal aims to discourage individuals from seeking emergency care for nonemergency situations and instead redirect them to appropriate primary healthcare services that already exist.

However, it is imperative to critically examine the context surrounding this proposed fee increase. Hong Kong’s public health services have traditionally offered lower fees than private healthcare settings, ensuring greater accessibility for a wide range of individuals, particularly those with limited financial means. This affordability has been a fundamental aspect of the public healthcare system, guaranteeing access to essential medical services for all members of society, regardless of their socioeconomic status.

Accurately determining the appropriate level of care within the emergency healthcare system poses significant challenges for the general public. This complex task requires individuals to navigate various factors and make well-informed decisions regarding the severity and urgency of their medical conditions. One of the key challenges lies in the general public’s lack of medical expertise and knowledge. Additionally, the availability and accessibility of alternative healthcare options also contribute to the challenges faced by the general public.

A pertinent study conducted in Hong Kong focused on three emergency departments located in the New Territories West Cluster. Published in the Hong Kong Medical Journal in 2023, the study utilized data obtained from the Hospital Authority’s Clinical Data Analysis and Reporting System. The research period spanned from April 1, 2018, to March 31, 2019, during which all patients and their respective visits to the three emergency departments were identified. The study encompassed 371,915 visits, accounting for 34 percent of the total visits in Hong Kong. To analyze the patient population, researchers categorized them into distinct groups based on visit frequency. “Frequent users” were defined as those who visited an emergency department on four to nine occasions, while “high-intensity users” were those with 10 or more visits. In contrast, “normal users” visited an emergency department on one to three occasions, and were the comparison group.

The findings of the study revealed that frequent users and highintensity users constituted 9 percent of all emergency department users but accounted for a substantial proportion of emergency department visits, representing 27.2 percent of the total visits. These individuals tended to be older, had a higher rate of payment exemption, and exhibited a greater likelihood of having underlying physical and mental health disorders. In terms of healthcare requirements, frequent users and high-intensity users demonstrated a higher likelihood of requiring ambulance services. They were also more likely to be triaged as urgent or above, indicating a more severe level in their conditions. Furthermore, these individuals exhibited a higher rate of hospitalization compared to normal users.

Based on the available evidence, it can be deduced that increasing fees associated with utilizing A&E services would not effectively reduce the attendance rate. This inefficiency primarily arises from a significant proportion of users being exempt from charges due to the existing social support program. Consequently, addressing the issue of A&E services misuse requires a comprehensive and holistic approach. However, before devising any strategies to tackle this challenge, it is crucial to develop a deeper understanding of these users. Their motivations for seeking care in an A&E department can be categorized into several groups, including limited access to primary care, high readmission rates among recently discharged patients, the perception of better resources and expertise, a sense of urgency and fear of deteriorating conditions, a lack of health literacy (particularly prevalent among ethnic minorities in Hong Kong), convenience and accessibility, perceived cost savings, and the need for sick-leave certificates (since some employers recognize only sick-leave certificates issued by government settings as valid documentation).

Given these considerations, adopting a comprehensive and holistic approach is crucial when addressing the issue of A&E services misuse. Simply increasing fees may not effectively target the underlying causes of misuse. Therefore, it is imperative to concurrently focus on improving primary healthcare services, enhancing public health education, and implementing measures to reduce readmissions among recently discharged patients. By strengthening primary healthcare, individuals will have improved access to appropriate care for nonemergency conditions and community care services for those with chronic illnesses. Public health education plays a pivotal role in raising awareness about the appropriate utilization of emergency care and guiding individuals toward the most suitable healthcare settings, especially among ethnic minorities. Additionally, optimizing the efficiency of the healthcare system through better discharge plans and patient management can help alleviate the strain on emergency departments.

While addressing the issue of misuse is important, it is equally crucial to consider the potential consequences of raising fees for A&E services. Such an increase may disproportionately affect lowincome individuals and those who genuinely require emergency care but are deterred by the financial burden. This could result in delayed or avoided care, potentially exacerbating health conditions and leading to more severe health outcomes. Therefore, it is imperative to carefully evaluate the implications of the proposed fee increase on access to emergency care, particularly for vulnerable populations.