Richard Yuen Ming-fai, Permanent Secretary for Food and Health (Health), Hong Kong: Exclusive Interview
On the eve of his retirement, Hong Kong’s health permanent secretary tells Matt Ross how the territory is reforming its healthcare system to prepare for a future in which half the population is of retirement age
Hong Kong’s population is ageing fast, explains Richard Yuen Ming-fai. “Right now, one in six of our population is 65 or over,” he says. “Probably, in 30 years’ time, it will be one in two. That’s a huge problem coming, a huge challenge.”
It is typical of the Hong Kong attitude to life that Yuen – the territory’s health permanent secretary for the last five years – sees the population’s rapid ageing as an opportunity as well as a challenge. “The next wave of economic growth will probably come from the healthcare sector,” he says. “Middle class people may not need to rely on the public health system: they have money, and they may want a choice of doctor, a choice of hospital, a better kind of service. That becomes an economic opportunity for the private healthcare system.”
Hong Kong, Yuen explains, operates a hybrid public-private healthcare system: local doctors are mainly private, but the government funds hospital care. “The cost of primary care is not that significant; most people are able to afford it,” he comments. “But admission to hospital is quite costly, so for serious disease we provide very good, comprehensive and well-trusted public hospitals. We call it the dual-track system.”
The 50-strong public hospital network has been run at arm’s length from government since 1990, when it was granted autonomy to get away from what Yuen calls the “weaknesses or challenges of a bureaucracy: long waiting times, inefficiency, lack of innovation”. As an independent, publicly-funded statutory body, he says, “it’s free from regulations and rules; they can adopt a private sector management style and philosophy.”
Here too there is a public/private split – for this public hospital network sits alongside a set of private providers: “If you have means and want more freedom, you can go into the private system,” Yuen explains. “But if it’s a serious illness or you don’t have that amount of money, the public hospitals will always take care of you.”
The organisational and sectoral boundaries running across this system do, Yuen concedes, make it difficult for medics to keep track of patients’ care histories. “People have to move between the public and private sectors. So in order for them to easily migrate between the two, we’re just starting the first phase of what we call the electronic health records system,” he explains. “If people subscribe, their health records will be digitised and stored in a central computer. That will facilitate the patients’ movement between the public and private sides, and enhance the quality of care.”
“Unfortunately, it’s only a voluntary system; we can’t go for a mandatory one,” he adds. “People are aware of their rights, of protection of privacy. When things are going smoothly for people, that sort of thing carries more weight. When they need an operation, they suddenly find that it’s very important to have that convenience.” The doctors are also resistant; so rather than try to force through a mandatory scheme, Yuen’s team are working to demonstrate its value with a willing set of patients. “We’re initially targeting people who need to go to the private and public hospitals frequently, so that other people can see the benefit and feel more assured; gradually, we expect, more people will join.”
So Hong Kong’s civil servants face the same kind of public concerns about privacy and control as those in many other developed nations. “As society develops, as people become more mature and affluent, they have higher expectations; they know their rights; they defend their interests,” comments Yuen. And this, he adds, helps explain the island city’s approach to organising the civil service – in which permanent teams of specialist officials are managed by a cadre of professional, generalist managers who move around the system. “Things have become more politicised,” he comments, “and therefore you need more generalists like us, to handle and deal with the political side.”
“The idea is to combine generalisation and specialisation” within the system, he explains. “Each department is staffed by technocrats: professionals who grow up in the department. Then on top of that are people like us, who float around. We try to bring a broader perspective to the operation of the department. We spend probably three or four years in one place, then when we go somewhere else we come in with open eyes and say: ‘Why do you do it like this? Is there another way to do it?’”
Having an itinerant senior management team also helps improve cross-departmental working, Yuen adds. Departments always “look after their own interests”, but these generalist leaders can consider issues “from a broader government perspective. We know how other people think, and if there’s anything that needs departments to work together, we can pick up the phone and talk to someone over there.”
In fact, when Yuen needs to build links between his health responsibilities and those in the closely-related field of food, he can just stroll down the corridor to talk to the bureau’s other permanent secretary – for his organisation holds both briefs, making it easier to address the public health issues around diet. “I’m responsible for public health, but on the food side they’re working to minimise the consumption of sugar and salt,” he explains. “We want to empower people with better knowledge of their health paths as they get older.”
The demographic challenge, however, will challenge Hong Kong’s ability to enact major reforms across organisational boundaries. “Chronic, age-related diseases like diabetes, hypertension, are incurable under the present medical technologies,” he points out. “That’s a major change for hospitals. Previously, most people would come into hospital for a procedure, stay for a few days and hopefully not return. But people with these chronic diseases keep coming back, and they gradually get worse for many years.”
Hospital treatment is expensive for government and inconvenient for frail, elderly patients, says Yuen, so officials are working to bring healthcare to the patients instead. “We need to redesign and enhance the facilities of [institutional] elderly homes to incorporate medical care – having a sick bay, for example,” he says. “And we want to send doctors out [into the community] to treat patients; that will relieve the congestion in hospitals, and let them go back to their core function of dealing with acute and emergency diseases. When old people are getting sick, is it right to require them to travel to the hospital? Why can’t we bring the doctor to their bedside?”
Hence the challenge around organisational boundaries – for public healthcare and social services sit “under two different roofs,” says Yuen. “We’re building up a partnership, a collaboration. But it needs a paradigm shift.”
On the health side, he adds, “you need the medical profession to say that the hospital is not really the best place to deal with [chronic, age-related diseases], and you need more professional training in geriatric services.” Meanwhile, elderly people’s homes and social services “need to improve their medical knowledge and capability to deal with elderly residents who have disorders and diseases. We need to deal with all this before the idea can work.”
Cross-departmental work is also important in addressing other contemporary challenges. Following a series of Far Eastern pandemics, Yuen argues that “the world is quite well prepared” for existing threats; but he points to the risk of new diseases emerging. “We’re trying all kinds of new inventions, playing with genes and things like that,” he comments. “You don’t know what will happen.”
A more immediate problem is that of Hong Kong citizens travelling abroad for medical or cosmetic treatment, and returning with complications made difficult to treat by inadequate care records (see news). “It’s very important for the health regulators of the world to come together to talk to one another more often, to deal with these sorts of issues,” he argues. “We’re all trying out new ideas, and that’s one way we can share experiences.”
This work, though, will fall to Yuen’s successor – for after a 36-year career in Hong Kong’s civil service, he retired at the end of last month. “We have a retirement age, and when we hit it we’re not expected to work – or at least, not to engage in anything that would have any perceived conflict of interest with previous jobs,” he explains. “So I may be forced to simply enjoy life – and, of course, to contribute to our growing age-related economy.”
See also our news piece on the challenges around international markets in medical and cosmetic procedures.
The Global Government Forum: Five Thoughts for Better Government
Richard Yuen Ming-fai on learning from overseas
To help our readers get the best out of Global Government Forum, we’ve started asking interviewees five standard questions – four seeking practical advice and opinions, and one to reveal something a little more personal. This is an edited version of Richard Yuen Ming-fai’s answers – click below to watch his full answers in a GGF video.
Can you name one lesson or idea from abroad that’s helped you or your colleagues in your working life?
“Two years [ago] I watched a programme which introduced an idea called the Dementia Village, in the Netherlands. Very often, dementia patients are bedridden or have to be confined, but in the Netherlands they have a village where patients can move around and be tracked by technology – so if they suddenly fall ill, you can respond.
“To preserve their way of life, they have a supermarket with special money just for them, so that they can continue shopping and things like that. That’s a wonderful idea; in fact, we’re trying it out in one of the new elderly homes in Hong Kong.
“As an officer delivering public policy – particularly in this part of the world – we often sacrifice the human touch in pursuit of efficiency. We look at public policy as a paper; work on it; deliver it. We forget the human dimension. So I shared this idea with my colleagues and contacts, saying that when we look at design or delivery of public policy, we must ensure that it doesn’t only work on paper, but also in reality. We must imagine ourselves to be the people who are going to be affected.”
Are there any projects or innovations in your country that might be useful to your peers overseas?
“I mentioned [in the main interview] our major project to relieve pressure on the public healthcare system. We’re pursuing this collaboration between medical and social services because with diseases like dementia, once people are diagnosed what they need most is carer support. There’s a huge burden, not so much on the public health system but on the family. So it’s very important for us to give them support for how to deal with it. The number [of patients] is so big that you can’t deal with it from the traditional supply side; rather, you have to deal with it from the demand side and mobilise community resources.
“You have to make better use of the elderly centre, the social services centre in the community; to put in facilities and ensure they know how to provide support for this chronic disease. I understand that other countries are also doing that, and that’s an area we can share with one another.”
How can we improve the ways in which senior officials work with and learn from their peers overseas?
“Know each other! That’s the most important thing: human touch. Even though today we have this technology, let’s sit together, have a couple of drinks, have coffee, play a round of golf and build up this personal relationship and trust, so that we can pick up the phone and talk.
“In terms of spread of disease, of people seeking treatment, it becomes globalised; there is no respect of boundaries and borders. But health authorities are still territory-based in terms of regulation, of health systems. So it’s very important to deal with this globalisation: to manage it by building up these connections. Global Government Forum is a very good platform to promote this personal touch and communication and networking.”
What are the biggest global challenges in your field over the next five years?
“It’s a recurring theme everywhere: the huge demand on the public healthcare system. We need completely new ideas and innovation to deal with it, because you can never train enough doctors: the challenge is not the number of patients, but the multiplication of diseases as people get older. We cannot build hospitals fast enough to deal with the demand for healthcare services in the traditional way, so we need new ideas.”
Finally, what’s your favourite book and why?
“People read for different reasons: for pleasure, for leisure or knowledge. But if we bring it back to my job as a public health officer, I think it would the book Guns, Germs and Steel by Jared Diamond.
“People have different views on the book, because it covers quite a big canvas of humankind’s development. But there’s a section on the spread of diseases which explains that many of the infectious diseases we face today actually come from the domestication of animals.
“Avian flu is from chickens. Smallpox, measles had similar roots. They started spreading from the 16th and 17th centuries because of exploration, the expansion of empire, bringing all those diseases and domesticated animals to new places in the world.
“The lesson for us now is that we are more or less repeating this sort of thing with globalisation. People travel so frequently. And we have enjoyed such a long period of relatively peaceful human development that the population multiplies very quickly, creating a lot of big cities with congested, dense populations. They are hotbeds for new diseases. And we can refresh our memories reading this book.”
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About Matt Ross
Matt is Global Government Forum's Contributing Editor, providing direction and support on topics, products and audience interests across GGF’s editorial, events and research operations. He has been a journalist and editor since 1995, beginning in motoring and travel journalism – and combining the two in a 30-month, 30-country 4x4 expedition funded by magazine photo-journalism. Between 2002 and 2008 he was Features Editor of Haymarket news magazine Regeneration & Renewal, covering urban regeneration, economic growth and community development; and from 2008 to 2014 he was the Editor of UK magazine and website Civil Service World, then Editorial Director for Public Sector – both at political publishing house Dods. He has also worked as Director of Communications at think tank the Institute for Government.
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