Mental health in Hong Kong: transition from hospital-based service to personalised care

Abstract

Hong Kong was a UK colony before 1997 but has since been a Special Administrative Region of the People’s Republic of China. It is located in southern China and has an area of 1104 km². Approximately 95% of Hong Kong’s population is ethnic Chinese. Hong Kong is a developed capitalist economy, with a gross domestic product of US$301.6 billion (2009 estimate), of which about 5.5% is spent on healthcare and about 0.24% on mental health (World Health Organization, 2005). Despite the relatively low level of spending on healthcare, Hong Kong nevertheless has one of the longest life expectancies in the world (79.2 years for men; 84.8 years for women) and a very low infant mortality rate (2.93 per 1000 live births) (Central Intelligence Agency, 2010).

Mental health policy and legislation

There is no specific mental health policy in Hong Kong. Instead, mental health services are subsumed within the overall health service of the territory, which is directed at the Hong Kong government level by the Food and Health Bureau. The lack of a coherent mental health policy has resulted in a lack of coordination between the medical sector, which provides assessment and treatment of mental disorders, and the social sector, which provides rehabilitation and ensures reintegration and support for people recovering from mental disorders (Hong Kong College of Psychiatrists, 2007).

On the other hand, a specific mental health ordinance was enacted in Hong Kong as early as 1906, in the form of the Asylums Ordinance, which underwent several major revisions and amendment in 1950, 1960, 1988 and 1997 (Lo, 1988; Cheung, 2000), during which process it became the Mental Health Ordinance of Hong Kong, largely based on the UK Mental Health Act 1983. In its current form, this ordinance contains provisions for: the management of the property and affairs of mentally incapacitated persons; the reception, detention and treatment of patients; guardianship; the admission of persons with a mental disorder who are involved in criminal proceedings; mental health review tribunals; and issues related to consent for medical and dental treatment for persons who are mentally incapacitated.

Mental health service delivery

Hong Kong has a mixed medical economy. A small proportion of specialist psychiatrists practise in the private sector. There is a lack of coverage of mental disorders by most medical insurance schemes. Consequently, the majority of mental healthcare in Hong Kong is provided by the public sector through the Hospital Authority (HA), a statutory body that manages all public hospitals in Hong Kong. Because of the relatively underdeveloped primary care system in Hong Kong, the mental health service has to take care of virtually all Hong Kong citizens who manage to access the public system with a mental health problem. To cope with the ever-increasing demand as the population becomes more aware of mental health problems, the service has evolved, over time, into a highly efficient system, characterised by high service throughput and efficient management of patients, but with a focus on risk aversion rather than personalised care.

The typical in-patient setting is an institutional one that ensures efficiency of management of a large number of patients; the total number of in-patients treated in 2008/09 was 15 887. A typical out-patient clinic is characterised by long waiting lists and a short consultation time per patient; the total number of out-patients served rose by 19% between 2003 and 2009. In 2009, a total of 151 259 out-patients were registered with the public system.

Since the year 2000, a number of small-scale initiatives and pilot programmes to reform the public mental health service have begun. These have concerned:

• the development of an early-intervention programme for young people with a first episode of psychosis

• the gradual down-sizing of large psychiatric hospitals – the total number of in-patient beds in Hong Kong decreased from 4730 in 2003/04 to 4000 in 2008/09

• funding to provide new psychiatric drugs for patients

• the gradual development and enhancement of community psychiatric services

• the development of community old-age psychiatric services, including outreach to institutions and a suicide prevention programme.

Although effective in their own right, most of these programmes were implemented only in selected areas of Hong Kong. After intensive lobbying by the Hong Kong College of Psychiatrists and other organisations, in 2009 the government announced that it would commit substantial resources in 2010 to two key areas: the implementation of a multidisciplinary case management approach in caring for patients with severe mental illness in the community; and the deployment of resources to develop shared care for common mental disorders with primary care practitioners.

The HA is also in the process of developing a Mental Health Service Plan that outlines the various strategies for mental health service development in the medical sector until 2015. This was the subject of consultation with various stakeholders in 2010.

Psychiatric training

Undergraduate medical training

Hong Kong has two medical schools, at the University of Hong Kong and the Chinese University of Hong Kong. The language of instruction in both universities is English and both medical schools have introduced problem-based learning, which has largely superseded traditional didactic teaching. Within the 5-year medical undergraduate course, psychiatry is taught in phases in the last 2 years. Medical students are expected to develop basic competencies in managing individuals with mental health problems through a combination of lectures, small-group tutorials and clinical bedside teaching.

Postgraduate training in psychiatry

Postgraduate training in psychiatry in Hong Kong is governed by the Hong Kong College of Psychiatrists, a constituent college of the Hong Kong Academy of Medicine, which is the statutory body responsible for overseeing the provision of specialist training and continuous medical education in Hong Kong. Historically, psychiatric training in Hong Kong has closely followed the UK system and most psychiatrists in Hong Kong obtained the Membership of the Royal College of Psychiatrists (MRCPsych) as part of their postgraduate training. Since the mid-1980s, psychiatric training in Hong Kong has been structured and accredited by the Royal College of Psychiatrists and the Hong Kong Training Scheme formally became a recognised training scheme for the MRCPsych examination.

After the formation of the Hong Kong Academy of Medicine in 1993, postgraduate training in psychiatry underwent further reform and became a 6-year programme. The first 3 years of basic training incorporate the pre-MRCPsych training scheme, giving the trainee the opportunity to take the MRCPsych examination or the Part II of the Fellowship Examination of the Hong Kong College of Psychiatrists (FHKCPsych). After this milestone, a further 3 years of higher training is required before a trainee is eligible to take Part III of the FHKCPsych, in which the submission and the successful oral defence of a research dissertation is required before the trainee can become a specialist in psychiatry in Hong Kong (Hong Kong College of Psychiatrists, 2008).

Postgraduate training for research in psychiatry is also available in the psychiatric departments of the two universities. Mental health professionals with an interest in pursuing postgraduate research training have opportunities to enrol on masters and doctoral programmes.

More recently, the Hong Kong College of Psychiatrists has embarked on the development and preparation of formal subspecialisation by forming clinical divisions in general adult psychiatry, old age psychiatry, child and adolescent psychiatry, psychotherapy, addiction psychiatry, rehabilitation psychiatry and learning disability.

Research

Despite its small size and lack of research funding, Hong Kong has a vibrant research scene in which multidisciplinary research addressing both neurobiological and psychosocial aspects of mental health takes place. The psychiatric departments of the two medical schools are the major research centres for psychiatry in Hong Kong. Particular areas of excellence include behavioural and statistical genetics, neuroimaging, research into early psychosis, sleep disorders, suicide and old-age psychiatry. In addition, applied and clinical research projects, such as clinical trials and service evaluations, are regularly conducted in HA hospitals throughout the territory.

Over the years, Hong Kong has also developed close research collaborations with major academic centres in mainland China, particularly in the area of psychosis, suicide and epidemiology.

Links with mainland China

Since the hand-over of Hong Kong in 1997, links between Hong Kong and mainland Chinese psychiatrists have gradually developed. Joint scientific conferences, exchanges and clinical attachments for psychiatrists are regularly organised between the two sides. In the past 3 years, a tripartite training scheme jointly organised by the Chinese University of Hong Kong, the University of Melbourne and local psychiatric institutes has facilitated the training of a large number of mainland psychiatrists and mental health workers. This has centred on imparting the knowledge, skills and practical information to implement community psychiatric care for patients with severe mental illness.

Future directions and conclusion

The mental health service in Hong Kong is undergoing tremendous change. With a firm foundation in education, training, legislation and research in psychiatry, despite meagre public spending on mental healthcare, Hong Kong has developed a highly efficient mental health service that addresses the basic mental health needs of its citizens with a hospital-based secondary and tertiary care model. However, this system is becoming unsustainable, because of the increasing pressure of demand. In the last 10 years or so, a gradual reform of the mental health service has begun. It is hoped that the service will be transformed from a system characterised by the efficient management of patients to a system that delivers personalised care to patients, informed by the cutting edge of psychiatric research.