Do the public think medical regulation keep them safe?

Do the public think medical regulation keep them safe? Abstract Objective To assess public knowledge and expectations of the ways to assess doctors’ competence to ensure patient safety. Design setting and participants Telephone survey of a random sample of 1000 non-institutionalized Hong Kong residents. Measures and results Only 5% of public were correct that doctors are not required to periodically be assessed, and 9% were correct that the doctors are not required to update knowledge and skills for renewing their license. These results echo international studies showing a low public knowledge of medical regulation. The public overwhelmingly felt a periodic assessment (92%) and requirements for continuous medical education (91%) were important processes for assuring doctors’ competence. A high proportion of the public felt that lay representation in the Medical Council was insufficient. Conclusion There is a significant gap between public expectations and understanding of the existing medical regulation and the actual policies and practices. Despite a lack of public knowledge, the public thought it important to have an ongoing structured monitoring and assessment mechanism to assure doctors’ competence. The public also expects a greater involvement in the regulatory processes as members of the Medical Council. There is a need to review and enhance the current regulatory system to meet public expectation and ensure accountability for the privilege and trust granted by the State in professional self-regulation. In the context of our complex health system, a thorough understanding on the dynamic interactions between different institutions and their complementary roles in a meta-regulatory framework is required in assuring patient safety. medical regulation, monitoring and assessment mechanism, lay representation Introduction Due to the advances in scientific knowledge and technology, and changes in clinical practices, medical regulators globally are facing challenges in medical regulation [1]. In an era of better informed patients and high profile reports of poor performance of doctors, the traditional approaches of professional regulation—based primarily on registration and licensing to ensure the minimum acceptable standards as a requirement for practice only at entry to the profession—might not be enough to ensure the quality and standards of care expected by patients [2]. There is a need to maintain doctors’ ongoing competence to ensure they continue to be fit-to-practice since the knowledge and skills obtained from undergraduate education and training rapidly become outdated. Therefore, many jurisdictions are undergoing reforms of medical regulation, triggered often by medical scandals and political pressure [3, 4]. One example is the case of Dr Harold Shipman, an general practitioner who murdered more than 200 of his older patients over a 20-year period, triggering substantial reforms of the regulation of doctors in the UK [5, 6]. Subsequent to the Shipman Inquiry, the Bristol pediatric surgery scandal and other medical incidents have led to the commissioning of a series of White Papers prompting the Government to introduce various measures to tighten educational and professional standards of doctors and to increase the transparency and accountability of professional regulatory bodies [7–9]. There is substantial evidence in international literature on the effectiveness of participation in continuous medical education (CME) in improving professional standards and patients’ outcomes [10–14]. The global trend is accelerating towards a compulsory requirement for all doctors to engage in CME to guide their professional development, and to continuously demonstrate their knowledge and skills are updated [3]. In addition, different mechanisms of performance assessment have been evolving worldwide beyond an emphasis on safety to a focus on improvements in performance through continuous measurement and feedback [3]. For example, processes of revalidation and recertification have been developed in the UK and USA, respectively, requiring individual doctors to demonstrate they meet acceptable contemporary professional standards and competence. These processes help to identify doctors who need early intervention and remediation [15–18]. In Hong Kong, the medical profession is self-regulating, defined as ‘the State granting the profession the right to regulate its conduct by developing the rules that it oversees and enforces with powers derived from legislation’ [19]. Specialists are mandated to participate in structured programs of continuous medical education and continuing professional development. Non-specialists participate only on a voluntary basis. There is no mandatory, structured and ongoing mechanism to assess and monitor all doctors’ performance in Hong Kong. Mechanisms to account to the public in the exercise of authority have not been commensurate with the privilege of the public trust in self-regulation. Only 14% of the membership of Medical Council in Hong Kong are lay members, i.e. a non-medical backgrounds. The dominance of medical professionals in the regulatory body runs counter to the global trend where lay representation is rising on medical regulatory boards. For example, lay representation in Australia is 33% and in the UK is 50% [3, 20, 21]. In Asian countries such as Singapore, Malaysia and mainland China, accountability for the authority is established through strong government oversight by virtue of their direct involvement in medical regulation. Globally, the role of the public is of growing importance in medical regulation, and there is a move from the premise that the profession is self-regulating, which is increasing seen as protecting its own interest, to a model of co-regulation in partnership with the public to better protect the public interest [3]. In addition, the public have a greater desire for more input and autonomy in the decisions about their care [2]. This has in turn influenced professional governance structures, as reflected in a greater desire for public accountability and transparency and more lay member representation on Medical Councils [2]. The objective of this paper is to assess public expectation of medical regulation in Hong Kong, focusing on two critical dimensions of medical governance: the structure of the medical regulatory body and the mechanisms to assess and monitor doctors’ performance and competence. The information from the public perspective provides an important insight for policy makers in considering the need for developing appropriate measures in assuring patient safety and in keeping with international trends in regulatory governance. Methods Study design and data collection This study was a cross-sectional telephone survey of a random sample of 1000 non-institutionalized Hong Kong residents. The inclusion criteria of respondents were Hong Kong residents aged 18 or above who were able to communicate in Cantonese. We excluded respondents who had hearing and language problems. Those who were mentally/cognitively incapacitated were also excluded. We targeted a minimum sample size of 1000 which would yield a precision level of plus/minus 3% from the true value at the 95% confidence level. Telephone numbers were randomly drawn from an up-to-dated residential telephone directory, and the telephone calls were made by a group of trained and experienced interviewers from June to July in 2014 at the Chinese University of Hong Kong. We adopted ‘last-birthday rule’ to select the household member whose birthday was the closest to the date of interview to complete the interview if there was more than one eligible person within a household. The respondents were informed of the purpose of the study prior to the conduct of interviews. Informed consent was sought verbally. Questionnaire We adopted a Knowledge, Attitudes and Practice model to guide the questionnaire design [22]. The questions were drafted taking reference to the literature on public views of medical regulation [23–25]. The questionnaire (available from corresponding author) covered three major areas (i) knowledge about the practice of regulation of medical doctors, (ii) attitudes towards medical regulation including (a) the importance of different monitoring processes that could be used to assure a doctor’s competence and (b) the structure of medical regulatory body, (iii) respondent’s demographics and health status. The knowledge of medical regulation was assessed by both asking the respondents’ self-perceived knowledge on the way doctors were assessed to ensure that the doctors were doing a good job, and testing the respondents’ knowledge on the requirements for a medical doctor to be able to practise in Hong Kong including (i) having a license from the Medical Council, (ii) affirming they have not been found guilty of professional misconduct as a condition of renewing their license; (iii) demonstrating they have up-to-date knowledge and skills needed to provide quality care as a condition for renewing their license and (iv) being periodically assessed to show that they are currently competent to practice safely. In assessing attitudes towards the monitoring processes to assure competency, we used a 4-point Likert Scale, ranging from ‘very important’ to ‘not at all important’ to report the relative importance of the following list of processes: (i) ‘taking part in the continuous medical education to keep knowledge and skills up-to-date’, (ii) ‘meeting certain performance assessment indicators e.g. high successful rate of treatments’, (iii) ‘receiving high rating from healthcare professionals with whom they work’, (iv) ‘receiving high rating from their patients’ and (v) ‘periodically assessed to show that they are currently competent to practice safely’. The questionnaire was reviewed and revised by experts and pilot-tested on 30 subjects before they were used in the main fieldwork. Outcome measures The primary outcome of the study is the perceived importance of different monitoring processes to assure a doctor’s competence for patient safety. Statistical analysis Descriptive statistics are reported by percentage. Association of socio-demographic variables with the primary outcome, i.e. five different monitoring and assessment mechanisms are first evaluated using univariate analysis. The variables that are significant in the univariate analysis are further analyzed by stepwise multiple logistic regressions to identify predictors and to estimate adjusted odds ratio (OR) with 95% confidence intervals (CI). A P-value of <0.05 is considered as statistically significant. Ethics approval Ethics approval was obtained for the study from the Survey and Behavioral Research Ethics Committee at the Chinese University of Hong Kong. Results A total of 1557 phone calls were made by the interviewers to eligible respondents. 1000 respondents successfully completed the survey, constituting an overall response rate of 64.2%. Characteristics of the study population Socio-demographic data of the respondents is shown in Table 1. There were 482 (48.2%) male respondents, and around one-third were 31–50 years old. The age profile of the sample was comparable to that of the general population in Hong Kong; 70.0% of the respondents had a regular/usually visited a doctor; 28.5% had ever been diagnosed by a doctor to have chronic diseases. Table 1 Demographic characteristics of 1000 respondents   Number  %  Age (years)   18–30  191  19.1   31–50  376  37.6   51–70  316  31.6   ≥71  117  11.7  Male  482  48.2  Working status (N = 997)a   Retired  227  22.8   Unemployed  35  3.5   Full-time student  79  7.9   Home-maker  237  23.8   Full-time worker  376  37.7   Part-time worker  43  4.3  Occupation for those full-time/part-time worker (N = 419)   Managers and administrators   Professionals  57  13.6   Associate professionals  35  8.3   Clerical support workers  96  22.9   Services and sales workers  142  33.9   Craft and related workers  29  6.9   Plant and machine operators and assemblers  10  2.4   Elementary occupations  21  5.0   Skilled agricultural and fishery workers and others  4  1.0  Household family income per month(HKD)b (N = 819)   ≤$4999  100  12.2   $5000–9999  49  6.0   $10 000–19 999  202  24.7   ≥$20 000  468  57.1  Received government allowance  156  15.6  Presence of chronic disease(s)  285  28.5  Perceived health status as compared with other people of same age (N = 995)   Better  272  27.3   Similar  622  62.5   Worse  101  10.2  Has a regular/usually visited doctor (N = 999)a  699  70  Doctor consultation in the past 1 month   No  617  61.7   Private sector only  185  18.5   Public sector only  167  16.7   Both public and private sector  31  3.1  Has been hospitalized in the past 1 year  103  10.3  Has health insurance coverage (N = 990)a  418  42.2    Number  %  Age (years)   18–30  191  19.1   31–50  376  37.6   51–70  316  31.6   ≥71  117  11.7  Male  482  48.2  Working status (N = 997)a   Retired  227  22.8   Unemployed  35  3.5   Full-time student  79  7.9   Home-maker  237  23.8   Full-time worker  376  37.7   Part-time worker  43  4.3  Occupation for those full-time/part-time worker (N = 419)   Managers and administrators   Professionals  57  13.6   Associate professionals  35  8.3   Clerical support workers  96  22.9   Services and sales workers  142  33.9   Craft and related workers  29  6.9   Plant and machine operators and assemblers  10  2.4   Elementary occupations  21  5.0   Skilled agricultural and fishery workers and others  4  1.0  Household family income per month(HKD)b (N = 819)   ≤$4999  100  12.2   $5000–9999  49  6.0   $10 000–19 999  202  24.7   ≥$20 000  468  57.1  Received government allowance  156  15.6  Presence of chronic disease(s)  285  28.5  Perceived health status as compared with other people of same age (N = 995)   Better  272  27.3   Similar  622  62.5   Worse  101  10.2  Has a regular/usually visited doctor (N = 999)a  699  70  Doctor consultation in the past 1 month   No  617  61.7   Private sector only  185  18.5   Public sector only  167  16.7   Both public and private sector  31  3.1  Has been hospitalized in the past 1 year  103  10.3  Has health insurance coverage (N = 990)a  418  42.2  aTotal number less than 1000 because of missing data. bHKD1 = USD0.128. Knowledge of medical regulation The respondents had a relatively low knowledge about the way doctors are being assessed to ensure that they are doing a good job. Most respondents reported to know little (67.3%) or nothing (8.9%) on the way doctors are being assessed (Table 2). A majority of respondents had correct knowledge about the requirement for doctors to be licensed by the Medical Council (95.2%) and the requirement to show that the doctor has not been found guilty of professional misconduct (86.1%). Only 4.6% of respondents were correct that all doctors are not required to be periodically assessed for competence to practice safely, and only 8.6% were correct that the doctors are not required to show that they have the up-to-date knowledge and skills as a condition of renewing their license. Table 2 Public knowledge of medical regulation   Number  %  Perceived knowledge   How much, if anything, do you know about the way doctors are assessed to ensure that they are doing a good job?    A great deal  7  0.7    Some amount  118  11.8    Not very much  673  67.3    Nothing at all  89  8.9    Don’t know  113  11.3  Test knowledge       To the best of your knowledge, are medical doctors practicing in Hong Kong required to ……   Be licensed by the Medical Council of Hong Kong    Yes (correct answer)  952  95.2    No  10  1.0    Don’t know  38  3.8   Be required to show they have up-to-date knowledge and skills needed to provide quality care as a condition of renewing their license    Yes  757  75.7    No (correct answer)  86  8.6    Don’t know  157  15.7   Be required to show they has not been found guilty of misconduct in a professional respect as a condition for renewing their license    Yes (correct answer)  861  86.1    No  43  4.3    Don’t know  96  9.6   Be periodically assessed to show they are currently competent to practice safely    Yes  877  87.7    No (correct answer)  46  4.6    Don’t know  77  7.7    Number  %  Perceived knowledge   How much, if anything, do you know about the way doctors are assessed to ensure that they are doing a good job?    A great deal  7  0.7    Some amount  118  11.8    Not very much  673  67.3    Nothing at all  89  8.9    Don’t know  113  11.3  Test knowledge       To the best of your knowledge, are medical doctors practicing in Hong Kong required to ……   Be licensed by the Medical Council of Hong Kong    Yes (correct answer)  952  95.2    No  10  1.0    Don’t know  38  3.8   Be required to show they have up-to-date knowledge and skills needed to provide quality care as a condition of renewing their license    Yes  757  75.7    No (correct answer)  86  8.6    Don’t know  157  15.7   Be required to show they has not been found guilty of misconduct in a professional respect as a condition for renewing their license    Yes (correct answer)  861  86.1    No  43  4.3    Don’t know  96  9.6   Be periodically assessed to show they are currently competent to practice safely    Yes  877  87.7    No (correct answer)  46  4.6    Don’t know  77  7.7  Attitudes Importance of monitoring processes to assure doctors’ competence ‘Receiving high rating from their patients’ (93.1%) and ‘Being periodically assessed to show that doctors are currently competent to practice safely’ (93.0%) were ranked as the most important processes to assure doctors’ competence, followed by ‘Meeting certain performance assessment indicators’ (91.5%) and ‘Taking part in continuous medical education to keep knowledge and skills up-to-date’ (90.6%). ‘Receiving high rating from healthcare professionals within whom doctors work’ was rated as relatively less important (73.4%) (Table 3). Table 3 Attitudes towards medical regulation   Number  %  Importance of a list of monitoring processes to assure a doctor’s competence   In your opinion, how importance is each of the following processes in assuring a doctor’s competence?   Taking part in continuous medical education to keep up-to-date knowledge and skill    Very important  256  25.6    Important  650  65.0    Not important  67  6.7    Not at all important  0  0.0    Don’t know  27  2.7   Meeting certain performance assessment indicators e.g. high successful rate of treatments    Very important  192  19.2    Important  723  72.3    Not important  54  5.4    Not at all important  1  0.1    Don’t know  30  3.0   Receiving high rating from healthcare professionals with whom they work    Very important  74  7.4    Important  660  66.0    Not important  218  21.8    Not at all important  5  0.5    Don’t know  43  4.3   Receiving high rating from their patients    Very important  235  23.5    Important  696  69.6    Not important  58  5.8    Not at all important  0  0.0    Don’t know  11  1.1   Being periodically assessed to show that they are currently competent to practice safely    Very important  255  25.5   Important  675  67.5    Not important  46  4.6    Not at all important  2  0.2    Don’t know  22  2.2  Structure of medical regulatory body   Do you think the current MCHK’s structure is sufficient to assure you confidence in the medical regulation?    Very sufficient  8  0.8    Sufficient  476  47.6    Insufficient  348  34.8    Very insufficient  36  3.6    Don’t know  132  13.2    Number  %  Importance of a list of monitoring processes to assure a doctor’s competence   In your opinion, how importance is each of the following processes in assuring a doctor’s competence?   Taking part in continuous medical education to keep up-to-date knowledge and skill    Very important  256  25.6    Important  650  65.0    Not important  67  6.7    Not at all important  0  0.0    Don’t know  27  2.7   Meeting certain performance assessment indicators e.g. high successful rate of treatments    Very important  192  19.2    Important  723  72.3    Not important  54  5.4    Not at all important  1  0.1    Don’t know  30  3.0   Receiving high rating from healthcare professionals with whom they work    Very important  74  7.4    Important  660  66.0    Not important  218  21.8    Not at all important  5  0.5    Don’t know  43  4.3   Receiving high rating from their patients    Very important  235  23.5    Important  696  69.6    Not important  58  5.8    Not at all important  0  0.0    Don’t know  11  1.1   Being periodically assessed to show that they are currently competent to practice safely    Very important  255  25.5   Important  675  67.5    Not important  46  4.6    Not at all important  2  0.2    Don’t know  22  2.2  Structure of medical regulatory body   Do you think the current MCHK’s structure is sufficient to assure you confidence in the medical regulation?    Very sufficient  8  0.8    Sufficient  476  47.6    Insufficient  348  34.8    Very insufficient  36  3.6    Don’t know  132  13.2  Univariate analysis was conducted to select the significant variables to put into the multiple logistic regression controlled for age and gender. The multiple logistic regression analysis (Table 4) showed that having a regular/usually visited doctor was associated with higher likelihood of supporting participation in continuous medical education (OR = 2.26, 95% CI: 1.37–3.75) and receiving a high rating from patients (OR = 2.20, 95% CI: 1.28–3.77) as important after adjusted age and gender. Table 4 Logistics regression for the importance of different monitoring processes to assure a doctor’s competence   Taking part in the continuous medical education  Meeting certain performance assessment indicators  High rating from healthcare professionals  High rating from their patients  Being periodically assessed  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  Gender   Male  1.27  (0.77, 2.11)  0.68  (0.39, 1.19)  Ref    0.75  (0.44, 1.28)  0.79  (0.46, 1.37)   Female  Ref  Ref  1.72  (1.17, 2.51)  Ref    Ref  Age   30 or below  0.69  (0.31, 1.57)  Ref  Ref  Ref  Ref   31–60  0.63  (0.34, 1.23)  2.59*  (1.40, 4.79)  0.89  (0.59, 1.34)  1.48  (0.74, 2.96)  1.63  (0.81, 3.26)   61 or above  Ref    3.50*  (1.54, 7.93)  0.92  (0.48, 1.73)  0.91  (0.43, 1.90)  0.85  (0.40, 1.80)  Working status   Retired/unemployed  –  –  –  –  1.14  (0.68, 1.92)  –  –  –  –   Students/Homemakers        –  0.55*  (0.37, 0.84)           Workers (Full/Part time)          Ref            Without hospitalized in past one year  –  –  –  –  0.66  (0.36, 1.21)  –  –  –  –  Without Health insurance  –  –  –  –      –  –  0.93  (0.52, 1.66)  Has a family doctor  2.26*  (1.37, 3.75)  2.74*  (1.57, 4.78)      2.20*  (1.28, 3.77)  –    With chronic diseases  –  –  –  –  1.32  (0.86, 2.03)  –  –  –  –  Knowledge  –  –  –  –      –  –  –  –   A great deal/some            (0.34, 1.72)           Not very much          0.41*  (0.21, 0.79)           Nothing at all          Ref              Taking part in the continuous medical education  Meeting certain performance assessment indicators  High rating from healthcare professionals  High rating from their patients  Being periodically assessed  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  Gender   Male  1.27  (0.77, 2.11)  0.68  (0.39, 1.19)  Ref    0.75  (0.44, 1.28)  0.79  (0.46, 1.37)   Female  Ref  Ref  1.72  (1.17, 2.51)  Ref    Ref  Age   30 or below  0.69  (0.31, 1.57)  Ref  Ref  Ref  Ref   31–60  0.63  (0.34, 1.23)  2.59*  (1.40, 4.79)  0.89  (0.59, 1.34)  1.48  (0.74, 2.96)  1.63  (0.81, 3.26)   61 or above  Ref    3.50*  (1.54, 7.93)  0.92  (0.48, 1.73)  0.91  (0.43, 1.90)  0.85  (0.40, 1.80)  Working status   Retired/unemployed  –  –  –  –  1.14  (0.68, 1.92)  –  –  –  –   Students/Homemakers        –  0.55*  (0.37, 0.84)           Workers (Full/Part time)          Ref            Without hospitalized in past one year  –  –  –  –  0.66  (0.36, 1.21)  –  –  –  –  Without Health insurance  –  –  –  –      –  –  0.93  (0.52, 1.66)  Has a family doctor  2.26*  (1.37, 3.75)  2.74*  (1.57, 4.78)      2.20*  (1.28, 3.77)  –    With chronic diseases  –  –  –  –  1.32  (0.86, 2.03)  –  –  –  –  Knowledge  –  –  –  –      –  –  –  –   A great deal/some            (0.34, 1.72)           Not very much          0.41*  (0.21, 0.79)           Nothing at all          Ref            *P-value < 0.05; **P-value <0.01; ***P-value <0.001. – Not significant in univariate analysis, so not included in the multiple logistic regression. With regard to the perceived importance of monitoring processes for meeting performance assessment indicators, multiple logistic regression showed that in addition to having a regular/usually visited doctor (OR = 2.74, 95% CI: 1.57–4.78), older age e.g. aged 31–60 (OR = 2.59, 95% CI: 1.40–4.79) and aged 61 or above (OR = 3.50, 95%CI: 1.54–7.93) were significant predictors. Those who were students/homemakers (relative to workers) (OR = 0.55, 95% CI: 0.37–0.84) and did not know very much about the ways doctors were assessed (relative to those knew nothing at all) (OR = 0.41, 95% CI: 0.21–0.79) were less likely to rate ‘receiving high rating from healthcare professionals’ as important. No significant predictors were found for periodic assessment to ensure competence. Structure of Medical Council Currently, the Medical Council of Hong Kong has 28 members of whom the majority [24] are medical practitioners, and four are lay members. Only 48.4% (less than half) thought this structure was adequate to assure respondents’ confidence in medical regulation (Table 3). 38.4% thought it was not adequate and 13.2% reported they did not know. Among those who thought the structure was inadequate to assure their confidence in the medical regulation (n = 384), most of them said it was due to the belief that doctors are protecting their own interest (55.2%), doctors self-regulate themselves (54.2%), there is too little public/patient representation (50.8%), there are too many medical practitioners (49.2%), and there are too few lay members (40.1%). Discussion Most of the public in Hong Kong thought all doctors are required to update their knowledge and to be periodically assessed, although in fact compulsory continuous medical education is only mandatory for specialists in Hong Kong. There is a significant gap between the public expectation and understanding of the existing regulatory framework for medical doctors and the actual policies and practices, as the public believe the regulator has the policies and procedures to ensure doctors are fit to practice. The results are similar to the findings of low public knowledge about medical regulation in Australia, UK and USA [23, 26, 27]. Despite a lack of knowledge about the regulatory system for the medical profession in Hong Kong, the public thought it was important to have all-rounded monitoring processes to ensure doctors are fit-to-practice. Similar findings were found in USA and Australia where the public ranked regular review of doctors’ practice as of high importance [26, 27]. Notwithstanding the low public knowledge of medical regulation in USA and UK in the last decade, different assessment and monitoring mechanisms have been developed and implemented in these jurisdictions to assess and identify ‘at-risk’ doctors for early intervention and remedial actions following many years of discussion in the community and active engagement of the government, profession and public during the process. For example, the revalidation program – an all-rounded assessment and monitoring mechanism launched in UK in 2012, which was catalyzed by the various medical scandals which led to questions of patient safety [15, 16]. The Medical Board in Australia is also actively engaging and collaborating with relevant stakeholders to strengthen continuous professional development and to proactively identify and assess doctors who are at risk [28]. There are also external levers driving improvement in the regulatory system such as the changes in the social-economic-political environment where patients and public desire greater transparency and accountability in medical regulation and more involvement in the decision making processes [29]. Given the complexity of medical regulation, public awareness of the regulatory mechanism in Hong Kong could be enhanced through dissemination of readily accessible and comprehensive information about doctors’ fitness to practice and procedures to uphold standards of practice and for handling complaints in line with other jurisdictions which have been improving accountability and transparency for privilege of self-regulation [2, 30]. There is emerging emphasis on increasing involvement of lay people in Medical Councils for greater transparency and accountability [3]. In our survey the public were of the view that lay representation was insufficient in the Medical Council. There was a strong feeling that doctors were protecting their own interests and a need to review the structure of Medical Council. In 2016 the Hong Kong Government submitted an Amendment Bill to the Legislative Council proposing, inter alia, an addition of lay members to the Medical Council to increase its capacity [31]. However, there was strong resistance to the Amendment Bill including a sit-in outside the Legislative Council building by around 400 doctors. The proposal was finally rejected by the Legislative Council after several weeks of discussion, due mainly to political concerns and the anxiety of the doctors union that professional autonomy could be compromised. Some also feared the government would loosen the regulations allowing foreign-trained doctors including doctors from mainland China to work in Hong Kong and that it might affect professional control of the supply of medical care. There were also arguments about different standards. The rejection reflects the high sense of self-protectionism amongst doctors in Hong Kong. Currently, medical regulation is shifting from profession’s self-regulation which is increasingly seen as protecting its own interest, to a co-regulation in partnership with the public to better protect the public interest [3]. Many jurisdictions are undergoing different types of regulatory reforms. Doctors in Hong Kong need to recognize the need to change to align with international trends and patient expectations. The current failed effort at medical regulatory reform in Hong Kong provides a lesson that reform requires a substantial period of discussion, engagement and management of the profession as the key stakeholder. Research is required to understand the views of professionals and their concerns in changing the current system. Providing the necessary training and support on an ongoing basis to lay members on the Medical Council is also essential so that they are equipped with appropriate knowledge and skill to carry out their role. This will also help to ensure that doctors understand the aims and importance of lay involvement as a mechanism for accountability as a prerequisite for the privilege of self-regulation [32]. In our complex health system, improving professional standards can only be achieved in a broader meta-regulatory framework in addition to the statutory regulation [33]. In addition to the desire for greater involvement of the public and their role in medical regulation, the complementary roles of different agents such as the providers and professionals are also indispensable in improving professional standards [2, 34]. Each agent has a role to play professional, and the scale of the contribution by each agent varies depending on the areas of expertise and concerns [35]. For example, in dealing with poor performance which includes an investigation and adjudication function, the law and regulators plays a relatively more important role. Whereas in providing guidance for professional development, professionals’ role and contributions are more significant. Specifically, medical professionalism is recognized as a critical motivation to drive patient safety and improvement in care [36]. Therefore, a thorough understanding on the dynamic interactions between relevant parties and their complementary roles in ensuring standards and improving quality is required. In addition, change for a more effective regulatory system requires an optimal balance between medical professionalism and external regulation. Any change should be implemented in phases with the support of the professions and the public with due consideration to meet the public expectation without undermining the professional motivation of individual doctors. Our study has some limitations. The sample for the public opinion survey was drawn from the non-institutionalized population with landlines. Findings may not apply to those who are institutionalized or those who do not own a telephone landline, including those with only mobile devices. However, as the fixed line telephone coverage in households in Hong Kong still exceeds 90% [37], a household telephone survey should only exclude a relatively small proportion of households. Conclusion Patients expect the Medical Council to have enabling policies and appropriate checks to ensure doctors remain competent and fit to practice, and assume that this already exists. Given the insufficient lay involvement in the Medical Council in Hong Kong, and the current lack of structured ongoing mechanisms for assessment and monitoring for medical doctors performance, there is a need to review and enhance the current regulatory system to meet public expectation and to be accountable for the privilege and trust granted by the State to the profession in self-regulation. Better information to the public through the generation and dissemination of relevant, accessible and quality information about medical regulation is required. Enhancement in professional development and identification of at risk or poorly-performing doctors through the development of different assessment and monitoring approaches should be examined to ensure standards of care. There is also a need to examine a meta-regulatory framework in addition to the statutory medical regulation, in which the complementary roles of different stakeholders including professionals, service providers and public are defined for improvements in professional standards. A more active role in influencing, advocacy and support from different stakeholders is needed to avoid some of the political pitfalls encountered in the process. Acknowledgments We are most grateful to interviewees for providing us valuable information. We sincerely thank the Food and Health Bureau of the Hong Kong Special Administrative Region in providing us funding and support to this study. Funding This work was supported by the Health and Medical Research Fund of the Food and Health Bureau of the Hong Kong Special Administrative Region [RFW-CUHK] Conflict of interest statement None declared. References 1 Kelly BD. Changing governance, governing change: medical regulation in Ireland. Ir J Med Sci  2010; 179: 3– 7. Google Scholar CrossRef Search ADS PubMed  2 Sutherland K, Leatherman S Regulation and Quality Improvement – A Review of the Evidence. 2006. 3 Yam C, Griffiths S, Liu S et al.  . Medical Regulation: ten key trends emerging from an international review. J Med Regul  2016; 102: 17– 28. 4 Allsop J, Jones K Quality Assurance in Medical Regulation in an International Context. 2006. 5 Department of Health U. Fifth Report – Safeguarding Patients: Lessons from the Past, Proposals for the Future. 2004. 6 Teasdale G. Learning from Bristol: report of the public inquiry into children’s heart surgery at Bristol Royal Infirmary 1984–1995. Br J Neurosurg  2002; 16: 211– 6. Google Scholar CrossRef Search ADS PubMed  7 Irvine D. Good doctors: safer patients – the Chief Medical Officer’s prescription for regulating doctors. J R Soc Med  2006; 99: 430– 2. Google Scholar CrossRef Search ADS PubMed  8 Department of Health U. 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Bills Committee on Medical Registration (Amendment) Bill 2016. 2016; LC Paper No. CB(2)1118/15-16(05). 32 Wallace J Layman’s Terms? The Involvement of Lay People in the Inspection of Public Services. 2004. 33 Department of Health U. Extending Professional and Occupational Regulation – The Report of the Working Group on Extending Professional Regulation. 2009. 34 Gagliardi AR, Lehoux P, Ducey A et al.  . Factors constraining patient engagement in implantable medical device discussions and decisions: interviews with physicians. Int J Qual Health Care  2017; 29: 276– 82. Google Scholar CrossRef Search ADS PubMed  35 Professional Standards Authority U. Right-touch regulation. 2010. 36 Royal College of Physicians, UK. Doctors in Society: Medical Professionalism in a Changing World. 2005. 37 Census and Statistics Department, Hong Kong. Monthly Digest of Statistics. 2015. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal for Quality in Health Care Oxford University Press

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Abstract

Abstract Objective To assess public knowledge and expectations of the ways to assess doctors’ competence to ensure patient safety. Design setting and participants Telephone survey of a random sample of 1000 non-institutionalized Hong Kong residents. Measures and results Only 5% of public were correct that doctors are not required to periodically be assessed, and 9% were correct that the doctors are not required to update knowledge and skills for renewing their license. These results echo international studies showing a low public knowledge of medical regulation. The public overwhelmingly felt a periodic assessment (92%) and requirements for continuous medical education (91%) were important processes for assuring doctors’ competence. A high proportion of the public felt that lay representation in the Medical Council was insufficient. Conclusion There is a significant gap between public expectations and understanding of the existing medical regulation and the actual policies and practices. Despite a lack of public knowledge, the public thought it important to have an ongoing structured monitoring and assessment mechanism to assure doctors’ competence. The public also expects a greater involvement in the regulatory processes as members of the Medical Council. There is a need to review and enhance the current regulatory system to meet public expectation and ensure accountability for the privilege and trust granted by the State in professional self-regulation. In the context of our complex health system, a thorough understanding on the dynamic interactions between different institutions and their complementary roles in a meta-regulatory framework is required in assuring patient safety. medical regulation, monitoring and assessment mechanism, lay representation Introduction Due to the advances in scientific knowledge and technology, and changes in clinical practices, medical regulators globally are facing challenges in medical regulation [1]. In an era of better informed patients and high profile reports of poor performance of doctors, the traditional approaches of professional regulation—based primarily on registration and licensing to ensure the minimum acceptable standards as a requirement for practice only at entry to the profession—might not be enough to ensure the quality and standards of care expected by patients [2]. There is a need to maintain doctors’ ongoing competence to ensure they continue to be fit-to-practice since the knowledge and skills obtained from undergraduate education and training rapidly become outdated. Therefore, many jurisdictions are undergoing reforms of medical regulation, triggered often by medical scandals and political pressure [3, 4]. One example is the case of Dr Harold Shipman, an general practitioner who murdered more than 200 of his older patients over a 20-year period, triggering substantial reforms of the regulation of doctors in the UK [5, 6]. Subsequent to the Shipman Inquiry, the Bristol pediatric surgery scandal and other medical incidents have led to the commissioning of a series of White Papers prompting the Government to introduce various measures to tighten educational and professional standards of doctors and to increase the transparency and accountability of professional regulatory bodies [7–9]. There is substantial evidence in international literature on the effectiveness of participation in continuous medical education (CME) in improving professional standards and patients’ outcomes [10–14]. The global trend is accelerating towards a compulsory requirement for all doctors to engage in CME to guide their professional development, and to continuously demonstrate their knowledge and skills are updated [3]. In addition, different mechanisms of performance assessment have been evolving worldwide beyond an emphasis on safety to a focus on improvements in performance through continuous measurement and feedback [3]. For example, processes of revalidation and recertification have been developed in the UK and USA, respectively, requiring individual doctors to demonstrate they meet acceptable contemporary professional standards and competence. These processes help to identify doctors who need early intervention and remediation [15–18]. In Hong Kong, the medical profession is self-regulating, defined as ‘the State granting the profession the right to regulate its conduct by developing the rules that it oversees and enforces with powers derived from legislation’ [19]. Specialists are mandated to participate in structured programs of continuous medical education and continuing professional development. Non-specialists participate only on a voluntary basis. There is no mandatory, structured and ongoing mechanism to assess and monitor all doctors’ performance in Hong Kong. Mechanisms to account to the public in the exercise of authority have not been commensurate with the privilege of the public trust in self-regulation. Only 14% of the membership of Medical Council in Hong Kong are lay members, i.e. a non-medical backgrounds. The dominance of medical professionals in the regulatory body runs counter to the global trend where lay representation is rising on medical regulatory boards. For example, lay representation in Australia is 33% and in the UK is 50% [3, 20, 21]. In Asian countries such as Singapore, Malaysia and mainland China, accountability for the authority is established through strong government oversight by virtue of their direct involvement in medical regulation. Globally, the role of the public is of growing importance in medical regulation, and there is a move from the premise that the profession is self-regulating, which is increasing seen as protecting its own interest, to a model of co-regulation in partnership with the public to better protect the public interest [3]. In addition, the public have a greater desire for more input and autonomy in the decisions about their care [2]. This has in turn influenced professional governance structures, as reflected in a greater desire for public accountability and transparency and more lay member representation on Medical Councils [2]. The objective of this paper is to assess public expectation of medical regulation in Hong Kong, focusing on two critical dimensions of medical governance: the structure of the medical regulatory body and the mechanisms to assess and monitor doctors’ performance and competence. The information from the public perspective provides an important insight for policy makers in considering the need for developing appropriate measures in assuring patient safety and in keeping with international trends in regulatory governance. Methods Study design and data collection This study was a cross-sectional telephone survey of a random sample of 1000 non-institutionalized Hong Kong residents. The inclusion criteria of respondents were Hong Kong residents aged 18 or above who were able to communicate in Cantonese. We excluded respondents who had hearing and language problems. Those who were mentally/cognitively incapacitated were also excluded. We targeted a minimum sample size of 1000 which would yield a precision level of plus/minus 3% from the true value at the 95% confidence level. Telephone numbers were randomly drawn from an up-to-dated residential telephone directory, and the telephone calls were made by a group of trained and experienced interviewers from June to July in 2014 at the Chinese University of Hong Kong. We adopted ‘last-birthday rule’ to select the household member whose birthday was the closest to the date of interview to complete the interview if there was more than one eligible person within a household. The respondents were informed of the purpose of the study prior to the conduct of interviews. Informed consent was sought verbally. Questionnaire We adopted a Knowledge, Attitudes and Practice model to guide the questionnaire design [22]. The questions were drafted taking reference to the literature on public views of medical regulation [23–25]. The questionnaire (available from corresponding author) covered three major areas (i) knowledge about the practice of regulation of medical doctors, (ii) attitudes towards medical regulation including (a) the importance of different monitoring processes that could be used to assure a doctor’s competence and (b) the structure of medical regulatory body, (iii) respondent’s demographics and health status. The knowledge of medical regulation was assessed by both asking the respondents’ self-perceived knowledge on the way doctors were assessed to ensure that the doctors were doing a good job, and testing the respondents’ knowledge on the requirements for a medical doctor to be able to practise in Hong Kong including (i) having a license from the Medical Council, (ii) affirming they have not been found guilty of professional misconduct as a condition of renewing their license; (iii) demonstrating they have up-to-date knowledge and skills needed to provide quality care as a condition for renewing their license and (iv) being periodically assessed to show that they are currently competent to practice safely. In assessing attitudes towards the monitoring processes to assure competency, we used a 4-point Likert Scale, ranging from ‘very important’ to ‘not at all important’ to report the relative importance of the following list of processes: (i) ‘taking part in the continuous medical education to keep knowledge and skills up-to-date’, (ii) ‘meeting certain performance assessment indicators e.g. high successful rate of treatments’, (iii) ‘receiving high rating from healthcare professionals with whom they work’, (iv) ‘receiving high rating from their patients’ and (v) ‘periodically assessed to show that they are currently competent to practice safely’. The questionnaire was reviewed and revised by experts and pilot-tested on 30 subjects before they were used in the main fieldwork. Outcome measures The primary outcome of the study is the perceived importance of different monitoring processes to assure a doctor’s competence for patient safety. Statistical analysis Descriptive statistics are reported by percentage. Association of socio-demographic variables with the primary outcome, i.e. five different monitoring and assessment mechanisms are first evaluated using univariate analysis. The variables that are significant in the univariate analysis are further analyzed by stepwise multiple logistic regressions to identify predictors and to estimate adjusted odds ratio (OR) with 95% confidence intervals (CI). A P-value of <0.05 is considered as statistically significant. Ethics approval Ethics approval was obtained for the study from the Survey and Behavioral Research Ethics Committee at the Chinese University of Hong Kong. Results A total of 1557 phone calls were made by the interviewers to eligible respondents. 1000 respondents successfully completed the survey, constituting an overall response rate of 64.2%. Characteristics of the study population Socio-demographic data of the respondents is shown in Table 1. There were 482 (48.2%) male respondents, and around one-third were 31–50 years old. The age profile of the sample was comparable to that of the general population in Hong Kong; 70.0% of the respondents had a regular/usually visited a doctor; 28.5% had ever been diagnosed by a doctor to have chronic diseases. Table 1 Demographic characteristics of 1000 respondents   Number  %  Age (years)   18–30  191  19.1   31–50  376  37.6   51–70  316  31.6   ≥71  117  11.7  Male  482  48.2  Working status (N = 997)a   Retired  227  22.8   Unemployed  35  3.5   Full-time student  79  7.9   Home-maker  237  23.8   Full-time worker  376  37.7   Part-time worker  43  4.3  Occupation for those full-time/part-time worker (N = 419)   Managers and administrators   Professionals  57  13.6   Associate professionals  35  8.3   Clerical support workers  96  22.9   Services and sales workers  142  33.9   Craft and related workers  29  6.9   Plant and machine operators and assemblers  10  2.4   Elementary occupations  21  5.0   Skilled agricultural and fishery workers and others  4  1.0  Household family income per month(HKD)b (N = 819)   ≤$4999  100  12.2   $5000–9999  49  6.0   $10 000–19 999  202  24.7   ≥$20 000  468  57.1  Received government allowance  156  15.6  Presence of chronic disease(s)  285  28.5  Perceived health status as compared with other people of same age (N = 995)   Better  272  27.3   Similar  622  62.5   Worse  101  10.2  Has a regular/usually visited doctor (N = 999)a  699  70  Doctor consultation in the past 1 month   No  617  61.7   Private sector only  185  18.5   Public sector only  167  16.7   Both public and private sector  31  3.1  Has been hospitalized in the past 1 year  103  10.3  Has health insurance coverage (N = 990)a  418  42.2    Number  %  Age (years)   18–30  191  19.1   31–50  376  37.6   51–70  316  31.6   ≥71  117  11.7  Male  482  48.2  Working status (N = 997)a   Retired  227  22.8   Unemployed  35  3.5   Full-time student  79  7.9   Home-maker  237  23.8   Full-time worker  376  37.7   Part-time worker  43  4.3  Occupation for those full-time/part-time worker (N = 419)   Managers and administrators   Professionals  57  13.6   Associate professionals  35  8.3   Clerical support workers  96  22.9   Services and sales workers  142  33.9   Craft and related workers  29  6.9   Plant and machine operators and assemblers  10  2.4   Elementary occupations  21  5.0   Skilled agricultural and fishery workers and others  4  1.0  Household family income per month(HKD)b (N = 819)   ≤$4999  100  12.2   $5000–9999  49  6.0   $10 000–19 999  202  24.7   ≥$20 000  468  57.1  Received government allowance  156  15.6  Presence of chronic disease(s)  285  28.5  Perceived health status as compared with other people of same age (N = 995)   Better  272  27.3   Similar  622  62.5   Worse  101  10.2  Has a regular/usually visited doctor (N = 999)a  699  70  Doctor consultation in the past 1 month   No  617  61.7   Private sector only  185  18.5   Public sector only  167  16.7   Both public and private sector  31  3.1  Has been hospitalized in the past 1 year  103  10.3  Has health insurance coverage (N = 990)a  418  42.2  aTotal number less than 1000 because of missing data. bHKD1 = USD0.128. Knowledge of medical regulation The respondents had a relatively low knowledge about the way doctors are being assessed to ensure that they are doing a good job. Most respondents reported to know little (67.3%) or nothing (8.9%) on the way doctors are being assessed (Table 2). A majority of respondents had correct knowledge about the requirement for doctors to be licensed by the Medical Council (95.2%) and the requirement to show that the doctor has not been found guilty of professional misconduct (86.1%). Only 4.6% of respondents were correct that all doctors are not required to be periodically assessed for competence to practice safely, and only 8.6% were correct that the doctors are not required to show that they have the up-to-date knowledge and skills as a condition of renewing their license. Table 2 Public knowledge of medical regulation   Number  %  Perceived knowledge   How much, if anything, do you know about the way doctors are assessed to ensure that they are doing a good job?    A great deal  7  0.7    Some amount  118  11.8    Not very much  673  67.3    Nothing at all  89  8.9    Don’t know  113  11.3  Test knowledge       To the best of your knowledge, are medical doctors practicing in Hong Kong required to ……   Be licensed by the Medical Council of Hong Kong    Yes (correct answer)  952  95.2    No  10  1.0    Don’t know  38  3.8   Be required to show they have up-to-date knowledge and skills needed to provide quality care as a condition of renewing their license    Yes  757  75.7    No (correct answer)  86  8.6    Don’t know  157  15.7   Be required to show they has not been found guilty of misconduct in a professional respect as a condition for renewing their license    Yes (correct answer)  861  86.1    No  43  4.3    Don’t know  96  9.6   Be periodically assessed to show they are currently competent to practice safely    Yes  877  87.7    No (correct answer)  46  4.6    Don’t know  77  7.7    Number  %  Perceived knowledge   How much, if anything, do you know about the way doctors are assessed to ensure that they are doing a good job?    A great deal  7  0.7    Some amount  118  11.8    Not very much  673  67.3    Nothing at all  89  8.9    Don’t know  113  11.3  Test knowledge       To the best of your knowledge, are medical doctors practicing in Hong Kong required to ……   Be licensed by the Medical Council of Hong Kong    Yes (correct answer)  952  95.2    No  10  1.0    Don’t know  38  3.8   Be required to show they have up-to-date knowledge and skills needed to provide quality care as a condition of renewing their license    Yes  757  75.7    No (correct answer)  86  8.6    Don’t know  157  15.7   Be required to show they has not been found guilty of misconduct in a professional respect as a condition for renewing their license    Yes (correct answer)  861  86.1    No  43  4.3    Don’t know  96  9.6   Be periodically assessed to show they are currently competent to practice safely    Yes  877  87.7    No (correct answer)  46  4.6    Don’t know  77  7.7  Attitudes Importance of monitoring processes to assure doctors’ competence ‘Receiving high rating from their patients’ (93.1%) and ‘Being periodically assessed to show that doctors are currently competent to practice safely’ (93.0%) were ranked as the most important processes to assure doctors’ competence, followed by ‘Meeting certain performance assessment indicators’ (91.5%) and ‘Taking part in continuous medical education to keep knowledge and skills up-to-date’ (90.6%). ‘Receiving high rating from healthcare professionals within whom doctors work’ was rated as relatively less important (73.4%) (Table 3). Table 3 Attitudes towards medical regulation   Number  %  Importance of a list of monitoring processes to assure a doctor’s competence   In your opinion, how importance is each of the following processes in assuring a doctor’s competence?   Taking part in continuous medical education to keep up-to-date knowledge and skill    Very important  256  25.6    Important  650  65.0    Not important  67  6.7    Not at all important  0  0.0    Don’t know  27  2.7   Meeting certain performance assessment indicators e.g. high successful rate of treatments    Very important  192  19.2    Important  723  72.3    Not important  54  5.4    Not at all important  1  0.1    Don’t know  30  3.0   Receiving high rating from healthcare professionals with whom they work    Very important  74  7.4    Important  660  66.0    Not important  218  21.8    Not at all important  5  0.5    Don’t know  43  4.3   Receiving high rating from their patients    Very important  235  23.5    Important  696  69.6    Not important  58  5.8    Not at all important  0  0.0    Don’t know  11  1.1   Being periodically assessed to show that they are currently competent to practice safely    Very important  255  25.5   Important  675  67.5    Not important  46  4.6    Not at all important  2  0.2    Don’t know  22  2.2  Structure of medical regulatory body   Do you think the current MCHK’s structure is sufficient to assure you confidence in the medical regulation?    Very sufficient  8  0.8    Sufficient  476  47.6    Insufficient  348  34.8    Very insufficient  36  3.6    Don’t know  132  13.2    Number  %  Importance of a list of monitoring processes to assure a doctor’s competence   In your opinion, how importance is each of the following processes in assuring a doctor’s competence?   Taking part in continuous medical education to keep up-to-date knowledge and skill    Very important  256  25.6    Important  650  65.0    Not important  67  6.7    Not at all important  0  0.0    Don’t know  27  2.7   Meeting certain performance assessment indicators e.g. high successful rate of treatments    Very important  192  19.2    Important  723  72.3    Not important  54  5.4    Not at all important  1  0.1    Don’t know  30  3.0   Receiving high rating from healthcare professionals with whom they work    Very important  74  7.4    Important  660  66.0    Not important  218  21.8    Not at all important  5  0.5    Don’t know  43  4.3   Receiving high rating from their patients    Very important  235  23.5    Important  696  69.6    Not important  58  5.8    Not at all important  0  0.0    Don’t know  11  1.1   Being periodically assessed to show that they are currently competent to practice safely    Very important  255  25.5   Important  675  67.5    Not important  46  4.6    Not at all important  2  0.2    Don’t know  22  2.2  Structure of medical regulatory body   Do you think the current MCHK’s structure is sufficient to assure you confidence in the medical regulation?    Very sufficient  8  0.8    Sufficient  476  47.6    Insufficient  348  34.8    Very insufficient  36  3.6    Don’t know  132  13.2  Univariate analysis was conducted to select the significant variables to put into the multiple logistic regression controlled for age and gender. The multiple logistic regression analysis (Table 4) showed that having a regular/usually visited doctor was associated with higher likelihood of supporting participation in continuous medical education (OR = 2.26, 95% CI: 1.37–3.75) and receiving a high rating from patients (OR = 2.20, 95% CI: 1.28–3.77) as important after adjusted age and gender. Table 4 Logistics regression for the importance of different monitoring processes to assure a doctor’s competence   Taking part in the continuous medical education  Meeting certain performance assessment indicators  High rating from healthcare professionals  High rating from their patients  Being periodically assessed  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  Gender   Male  1.27  (0.77, 2.11)  0.68  (0.39, 1.19)  Ref    0.75  (0.44, 1.28)  0.79  (0.46, 1.37)   Female  Ref  Ref  1.72  (1.17, 2.51)  Ref    Ref  Age   30 or below  0.69  (0.31, 1.57)  Ref  Ref  Ref  Ref   31–60  0.63  (0.34, 1.23)  2.59*  (1.40, 4.79)  0.89  (0.59, 1.34)  1.48  (0.74, 2.96)  1.63  (0.81, 3.26)   61 or above  Ref    3.50*  (1.54, 7.93)  0.92  (0.48, 1.73)  0.91  (0.43, 1.90)  0.85  (0.40, 1.80)  Working status   Retired/unemployed  –  –  –  –  1.14  (0.68, 1.92)  –  –  –  –   Students/Homemakers        –  0.55*  (0.37, 0.84)           Workers (Full/Part time)          Ref            Without hospitalized in past one year  –  –  –  –  0.66  (0.36, 1.21)  –  –  –  –  Without Health insurance  –  –  –  –      –  –  0.93  (0.52, 1.66)  Has a family doctor  2.26*  (1.37, 3.75)  2.74*  (1.57, 4.78)      2.20*  (1.28, 3.77)  –    With chronic diseases  –  –  –  –  1.32  (0.86, 2.03)  –  –  –  –  Knowledge  –  –  –  –      –  –  –  –   A great deal/some            (0.34, 1.72)           Not very much          0.41*  (0.21, 0.79)           Nothing at all          Ref              Taking part in the continuous medical education  Meeting certain performance assessment indicators  High rating from healthcare professionals  High rating from their patients  Being periodically assessed  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  OR  (95% CI)  Gender   Male  1.27  (0.77, 2.11)  0.68  (0.39, 1.19)  Ref    0.75  (0.44, 1.28)  0.79  (0.46, 1.37)   Female  Ref  Ref  1.72  (1.17, 2.51)  Ref    Ref  Age   30 or below  0.69  (0.31, 1.57)  Ref  Ref  Ref  Ref   31–60  0.63  (0.34, 1.23)  2.59*  (1.40, 4.79)  0.89  (0.59, 1.34)  1.48  (0.74, 2.96)  1.63  (0.81, 3.26)   61 or above  Ref    3.50*  (1.54, 7.93)  0.92  (0.48, 1.73)  0.91  (0.43, 1.90)  0.85  (0.40, 1.80)  Working status   Retired/unemployed  –  –  –  –  1.14  (0.68, 1.92)  –  –  –  –   Students/Homemakers        –  0.55*  (0.37, 0.84)           Workers (Full/Part time)          Ref            Without hospitalized in past one year  –  –  –  –  0.66  (0.36, 1.21)  –  –  –  –  Without Health insurance  –  –  –  –      –  –  0.93  (0.52, 1.66)  Has a family doctor  2.26*  (1.37, 3.75)  2.74*  (1.57, 4.78)      2.20*  (1.28, 3.77)  –    With chronic diseases  –  –  –  –  1.32  (0.86, 2.03)  –  –  –  –  Knowledge  –  –  –  –      –  –  –  –   A great deal/some            (0.34, 1.72)           Not very much          0.41*  (0.21, 0.79)           Nothing at all          Ref            *P-value < 0.05; **P-value <0.01; ***P-value <0.001. – Not significant in univariate analysis, so not included in the multiple logistic regression. With regard to the perceived importance of monitoring processes for meeting performance assessment indicators, multiple logistic regression showed that in addition to having a regular/usually visited doctor (OR = 2.74, 95% CI: 1.57–4.78), older age e.g. aged 31–60 (OR = 2.59, 95% CI: 1.40–4.79) and aged 61 or above (OR = 3.50, 95%CI: 1.54–7.93) were significant predictors. Those who were students/homemakers (relative to workers) (OR = 0.55, 95% CI: 0.37–0.84) and did not know very much about the ways doctors were assessed (relative to those knew nothing at all) (OR = 0.41, 95% CI: 0.21–0.79) were less likely to rate ‘receiving high rating from healthcare professionals’ as important. No significant predictors were found for periodic assessment to ensure competence. Structure of Medical Council Currently, the Medical Council of Hong Kong has 28 members of whom the majority [24] are medical practitioners, and four are lay members. Only 48.4% (less than half) thought this structure was adequate to assure respondents’ confidence in medical regulation (Table 3). 38.4% thought it was not adequate and 13.2% reported they did not know. Among those who thought the structure was inadequate to assure their confidence in the medical regulation (n = 384), most of them said it was due to the belief that doctors are protecting their own interest (55.2%), doctors self-regulate themselves (54.2%), there is too little public/patient representation (50.8%), there are too many medical practitioners (49.2%), and there are too few lay members (40.1%). Discussion Most of the public in Hong Kong thought all doctors are required to update their knowledge and to be periodically assessed, although in fact compulsory continuous medical education is only mandatory for specialists in Hong Kong. There is a significant gap between the public expectation and understanding of the existing regulatory framework for medical doctors and the actual policies and practices, as the public believe the regulator has the policies and procedures to ensure doctors are fit to practice. The results are similar to the findings of low public knowledge about medical regulation in Australia, UK and USA [23, 26, 27]. Despite a lack of knowledge about the regulatory system for the medical profession in Hong Kong, the public thought it was important to have all-rounded monitoring processes to ensure doctors are fit-to-practice. Similar findings were found in USA and Australia where the public ranked regular review of doctors’ practice as of high importance [26, 27]. Notwithstanding the low public knowledge of medical regulation in USA and UK in the last decade, different assessment and monitoring mechanisms have been developed and implemented in these jurisdictions to assess and identify ‘at-risk’ doctors for early intervention and remedial actions following many years of discussion in the community and active engagement of the government, profession and public during the process. For example, the revalidation program – an all-rounded assessment and monitoring mechanism launched in UK in 2012, which was catalyzed by the various medical scandals which led to questions of patient safety [15, 16]. The Medical Board in Australia is also actively engaging and collaborating with relevant stakeholders to strengthen continuous professional development and to proactively identify and assess doctors who are at risk [28]. There are also external levers driving improvement in the regulatory system such as the changes in the social-economic-political environment where patients and public desire greater transparency and accountability in medical regulation and more involvement in the decision making processes [29]. Given the complexity of medical regulation, public awareness of the regulatory mechanism in Hong Kong could be enhanced through dissemination of readily accessible and comprehensive information about doctors’ fitness to practice and procedures to uphold standards of practice and for handling complaints in line with other jurisdictions which have been improving accountability and transparency for privilege of self-regulation [2, 30]. There is emerging emphasis on increasing involvement of lay people in Medical Councils for greater transparency and accountability [3]. In our survey the public were of the view that lay representation was insufficient in the Medical Council. There was a strong feeling that doctors were protecting their own interests and a need to review the structure of Medical Council. In 2016 the Hong Kong Government submitted an Amendment Bill to the Legislative Council proposing, inter alia, an addition of lay members to the Medical Council to increase its capacity [31]. However, there was strong resistance to the Amendment Bill including a sit-in outside the Legislative Council building by around 400 doctors. The proposal was finally rejected by the Legislative Council after several weeks of discussion, due mainly to political concerns and the anxiety of the doctors union that professional autonomy could be compromised. Some also feared the government would loosen the regulations allowing foreign-trained doctors including doctors from mainland China to work in Hong Kong and that it might affect professional control of the supply of medical care. There were also arguments about different standards. The rejection reflects the high sense of self-protectionism amongst doctors in Hong Kong. Currently, medical regulation is shifting from profession’s self-regulation which is increasingly seen as protecting its own interest, to a co-regulation in partnership with the public to better protect the public interest [3]. Many jurisdictions are undergoing different types of regulatory reforms. Doctors in Hong Kong need to recognize the need to change to align with international trends and patient expectations. The current failed effort at medical regulatory reform in Hong Kong provides a lesson that reform requires a substantial period of discussion, engagement and management of the profession as the key stakeholder. Research is required to understand the views of professionals and their concerns in changing the current system. Providing the necessary training and support on an ongoing basis to lay members on the Medical Council is also essential so that they are equipped with appropriate knowledge and skill to carry out their role. This will also help to ensure that doctors understand the aims and importance of lay involvement as a mechanism for accountability as a prerequisite for the privilege of self-regulation [32]. In our complex health system, improving professional standards can only be achieved in a broader meta-regulatory framework in addition to the statutory regulation [33]. In addition to the desire for greater involvement of the public and their role in medical regulation, the complementary roles of different agents such as the providers and professionals are also indispensable in improving professional standards [2, 34]. Each agent has a role to play professional, and the scale of the contribution by each agent varies depending on the areas of expertise and concerns [35]. For example, in dealing with poor performance which includes an investigation and adjudication function, the law and regulators plays a relatively more important role. Whereas in providing guidance for professional development, professionals’ role and contributions are more significant. Specifically, medical professionalism is recognized as a critical motivation to drive patient safety and improvement in care [36]. Therefore, a thorough understanding on the dynamic interactions between relevant parties and their complementary roles in ensuring standards and improving quality is required. In addition, change for a more effective regulatory system requires an optimal balance between medical professionalism and external regulation. Any change should be implemented in phases with the support of the professions and the public with due consideration to meet the public expectation without undermining the professional motivation of individual doctors. Our study has some limitations. The sample for the public opinion survey was drawn from the non-institutionalized population with landlines. Findings may not apply to those who are institutionalized or those who do not own a telephone landline, including those with only mobile devices. However, as the fixed line telephone coverage in households in Hong Kong still exceeds 90% [37], a household telephone survey should only exclude a relatively small proportion of households. Conclusion Patients expect the Medical Council to have enabling policies and appropriate checks to ensure doctors remain competent and fit to practice, and assume that this already exists. Given the insufficient lay involvement in the Medical Council in Hong Kong, and the current lack of structured ongoing mechanisms for assessment and monitoring for medical doctors performance, there is a need to review and enhance the current regulatory system to meet public expectation and to be accountable for the privilege and trust granted by the State to the profession in self-regulation. Better information to the public through the generation and dissemination of relevant, accessible and quality information about medical regulation is required. Enhancement in professional development and identification of at risk or poorly-performing doctors through the development of different assessment and monitoring approaches should be examined to ensure standards of care. There is also a need to examine a meta-regulatory framework in addition to the statutory medical regulation, in which the complementary roles of different stakeholders including professionals, service providers and public are defined for improvements in professional standards. A more active role in influencing, advocacy and support from different stakeholders is needed to avoid some of the political pitfalls encountered in the process. Acknowledgments We are most grateful to interviewees for providing us valuable information. We sincerely thank the Food and Health Bureau of the Hong Kong Special Administrative Region in providing us funding and support to this study. Funding This work was supported by the Health and Medical Research Fund of the Food and Health Bureau of the Hong Kong Special Administrative Region [RFW-CUHK] Conflict of interest statement None declared. References 1 Kelly BD. Changing governance, governing change: medical regulation in Ireland. 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Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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International Journal for Quality in Health CareOxford University Press

Published: Mar 1, 2018

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