Replies to LegCo questions
LCQ7: Treatment and follow-up care for psychiatric patients
Following is a question by the Hon Yung Hoi-yan and a written reply by the
Secretary for Food and Health, Dr Ko Wing-man, in the Legislative Council today
(June 14):
Question:
The Hospital Authority (HA) launched the Case Management Programme in different
districts of Hong Kong by phases in the 2010-2011 financial year to provide
community support services for patients with severe mental illness (SMI), and
extended the Programme in the 2014-2015 financial year to cover all 18 districts
across the territory. As at March 31 last year, HA employed a total of 327 case
managers to take care of over 15 400 patients with SMI (i.e. each case manager
needed to take care of about 47 patients on average). Some mental illness
concern groups have pointed out that the wastage of case managers has been
serious in recent years and the manpower shortage problem has become
increasingly serious (for example, the current case manager-to-patient ratio in
a certain hospital cluster is as high as 1:70). Such concern groups have also
pointed out that long-acting injectable antipsychotics (LAIAs) help reduce the
relapse chance of patients (particularly those who do not take medication on
time), and patients who receive LAIAs at the early stage of their illness may
obtain better curative effect, which will benefit both patients and their
families in the long run. In this connection, will the Government inform this
Council:
(1) whether it knows the number of case managers and the number of patients with
SMI whom such case managers took care of, in the past three financial years,
broken down by hospital cluster (set out in a table);
(2) whether it knows the criteria currently adopted by HA for determining which
patients with SMI should be taken care of by case managers, and the average time
taken for following up each case at present;
(3) whether it knows the number of patients with mental illness who are
currently not being taken care of by case managers and whose conditions are
stable but serious; whether HA has followed up and monitored the conditions of
such patients through other channels; if HA has, of the details; if not, the
reasons for that;
(4) given that the relevant case manager-to-patient ratios in quite a number of
advanced countries (e.g. Australia, the United States) range from about 1:20 to
1:25 at present, whether it knows if HA has assessed the number of additional
case managers HA needs to recruit in order to be on par with those countries; if
HA has assessed, of the outcome, including the number of additional case
managers HA needs to recruit, the implementation timetable and the expenditure
involved; whether HA will formulate short, medium and long-term improvement
measures to reduce the workload of case managers;
(5) whether it knows if HA will formulate a long-term strategy to enhance case
management standards; if HA will, of the specific contents of and implementation
timetable for the relevant long-term strategy; of the measures HA has in place
to enhance the training for case managers;
(6) whether it knows HA's estimated expenditure on drugs for patients with SMI
in the current financial year and how such estimated expenditure compares with
the actual expenditure in the last financial year;
(7) whether it knows, among the patients with mental illness in various public
hospitals in the last financial year, the respective numbers and percentages of
those who took (i) first-generation and (ii) second-generation oral
antipsychotics, and those who received (iii) first-generation and (iv)
second-generation LAIAs (set out in a table); and
(8) whether it will allocate additional resources to HA so that more patients
with mental illness will be provided with LAIAs, especially second-generation
LAIAs which have less side effects; if so, of the details; if not, the reasons
for that; whether it has plans to categorise LAIAs as first-line drugs in HA's
Drug Formulary in the long run?
Reply:
President,
The Hospital Authority (HA) adopts a multi-disciplinary approach in its
provision of psychiatric specialist services. The multi-disciplinary teams,
comprising psychiatric doctors, psychiatric nurses, clinical psychologists and
occupational therapists, provide patients, depending on their conditions and
clinical needs, with the appropriate treatment and follow-up care, including
in-patient, specialist out-patient, daytime rehabilitative training and
community support services. My reply to the various parts of the question is as
follows:
(1) to (5) The Community Psychiatric Services of HA provides a range of
community psychiatric services, including Community Psychiatric Nursing
Services, Case Management Programme, Intensive Care Teams and Mental Health
Direct hotline, for needy patients according to their conditions, clinical needs
and risk levels.
The HA launched the Case Management Programme for patients with severe mental
illness (SMI) under its Community Psychiatric Services by phases from 2010-11 to
proactively provide intensive, continuous and personalised support for patients
with SMI residing in the community. Under the programme, case managers work
closely with other service providers (particularly the Integrated Community
Centres for Mental Wellness (ICCMWs) set up by the Social Welfare Department
(SWD)) to provide community support for the target patients. In 2014-15, the
programme was extended to cover all 18 districts across the territory to benefit
more patients.
Table 1 at annex sets out the numbers of case managers and cases handled under
HA's Case Management Programme in the past three years.
At present, psychiatric doctors of HA decide whether to refer patients with
mental illness to the Community Psychiatric Services for follow-up according to
the patients' conditions and their clinical needs. Patients may also be referred
to Community Psychiatric Services through various channels such as ICCMWs funded
by SWD or social workers. Upon receiving the referred cases, the
multi-disciplinary community psychiatric teams will provide patients with the
appropriate community support services.
Except for the few patients who decline the services (note 1), all others who
are considered suitable will be arranged to receive community psychiatric
follow-up services according to their conditions and clinical needs.
As the number and duration of visits for each case under Community Psychiatric
Services vary depending on the seriousness of illness, clinical needs and risk
levels of the patient, HA does not maintain the average time taken for following
up on each case.
In April this year, the Review Committee on Mental Health published the Mental
Health Review Report. It recommends, among other things, that in order to
further enhance the support for patients with SMI and lessen the burden on case
managers, the HA should improve the ratio of case manager to patients with SMI.
The preliminary target was set at improving the ratio from the current 1:50 to
around 1:40 in three to five years' time. As such, HA will conduct a
comprehensive review of the planning of Community Psychiatric Services and the
manpower and training arrangements of case managers within this financial year.
(6) to (8) Over the years, HA has made every effort to increase the use of new
generation psychiatric drugs which have proven effectiveness with fewer side
effects, including antipsychotic drugs, antidepressant drugs, drugs for dementia
and attention deficit/hyperactivity disorder. Taking the patients' wish into
account, psychiatrists will provide necessary drug treatment for patients as
appropriate, having regard to their clinical needs and in accordance with the
clinical treatment protocol. The number of patients prescribed with the new
generation antipsychotic drugs and ampoules (note 2) at public hospitals has
increased from about 39 200 in the 2010-11 financial year to 82 300 in the
2016-17 financial year, representing an increase of almost 110 per cent.
In the 2014-15 financial year, HA repositioned the new generation oral
antipsychotic drugs (save for Clozapine due to its more complicated side
effects) from the special drug category to the general drug category in its Drug
Formulary so that all these drugs could be prescribed as first-line drugs.
The new generation long-acting antipsychotic ampoule have already been
incorporated into the special drug category of HA's Drug Formulary.
Psychiatrists will provide necessary drug treatment for patients as appropriate,
having regard to their clinical needs and in accordance with the clinical
treatment protocol.
Table 2 at annex sets out the respective number and percentage of psychiatric
patients of HA who were prescribed traditional or new generation oral
antipsychotic drugs and traditional or new generation long-acting antipsychotic
ampoules in the 2016-17 financial year.
The HA has put into place an established mechanism under which experts examine
and review regularly the treatment options and drugs for patients with
adjustments made as appropriate, taking into account factors like scientific
evidences, clinical risks and treatment efficacy, technological advancement and
views of patient groups, etc. The HA will continue to closely monitor the latest
development of the clinical and scientific evidences of new psychiatric drugs.
It will continue to review and introduce new drugs, and formulate guidelines for
clinical use of such drugs in accordance with the established mechanism having
regard to the principle of optimising the use of public resources and providing
the most appropriate drug treatment for needy patients.
Note 1: If a patient is a conditionally discharged patient under section 42B of
the Mental Health Ordinance (Cap. 136), the medical superintendent may require
the patient to receive community psychiatric services or otherwise may recall
the patient to the mental hospital.
Note 2: Including long-acting and short-acting ampoules.
Ends/Wednesday, June 14, 2017
Issued at HKT 15:40
NNNN
LCQ7 Annex