From hospitals to community

Perhaps the most significant change in mental healthcare in Hong Kong over the past decade is the dramatic transition from hospital-based to community-based services (Hospital Authority 2001, 2013a). The number of psychiatric beds under the Hospital Authority peaked in 2000, when there were 5395 beds distributed across two psychiatric hospitals and ten general hospitals. The size of in-patient facilities then started to decrease. According to the latest Hospital Authority statistics, there were 3607 psychiatric beds in 2012, representing a reduction of 33% over the past 12 years (Hospital Authority 2013a). Meanwhile, psychiatric out-patient attendances have been increasing steadily from 432 046 in 2000 to 755 745 in 2012 – a rise of almost 75%. Psychiatric day hospital attendances also increased, from 146 729 in 2000 to 220 532 in 2012, a rise of around 50%. In addition, community psychiatric services provided 42 756 home visits in 2000. Twelve years later, 198 354 home visits were made to patients receiving community psychiatric services.

In line with the enhancement of community psychiatric services, a number of programmes specific to disease phases have been introduced over the past few years. A notable example is the Early Assessment Service for Young People with Psychosis (EASY) programme, which consists of public awareness, early detection and specialised case management. A recent cohort study showed that patients in the EASY group had longer full-time employment or study, fewer days of hospital admissions, fewer suicides and disengagements from services than the historical control group (Reference Chen, Tang and HuiChen 2011). Specialised treatment programmes catering for different age-specific disorders, for instance, the Elderly Suicide Prevention Programme, have also been developed.

Challenges

Although there have been exciting developments, we are facing significant challenges in various areas. Some of these challenges are not new to mental health professionals from other parts of the world, for example the prevailing stigma towards mental health problems, fragmentation of healthcare system and a lack of dedicated mental health funds. But others are less frequently encountered by our overseas counterparts. For example, crowded living conditions in Hong Kong have posed unexpected difficulty in the delivery of psychiatric treatment in the community. By mid-2012, the population density of Hong Kong stood at a staggering 6620 persons per square kilometre (Information Services Department 2013). It is drastically higher than in most high-income countries/regions such as Japan (351/km²), the UK (259/km²) and the USA (34/km²) (World Bank 2014). The overcrowded living conditions have made family members unwilling or unable to support patients in the community, especially during periods when they need more intensive care. Besides, at least some patients find hospital care a desirable alternative when compared with their own accommodation.

Another significant challenge in Hong Kong is the inadequate involvement of primary care services in the provision of mental healthcare. Unlike health systems in countries such as the UK, a large proportion of primary care in Hong Kong is provided by general practitioners in the private sector. It is therefore not surprising that the public specialist psychiatric services operated by the Hospital Authority, which is heavily subsidised by the government, draw most of the patients. This is reflected in the steady rise in the number of patients receiving the Hospital Authority psychiatric services (including inpatient, specialist out-patient, day hospital and psychiatric community services) from 147 557 in 2007–2008 to 186 907 in 2011–2012, an increase of 26% (Hong Kong Government Information Centre 2012). The unsatisfactory interface between primary care and specialist psychiatric services has made the latter overloaded. The waiting time for psychiatric services has therefore been lengthening over the years: in routine cases in 2013, around 90% of individuals waited 81 weeks for a first appointment at a psychiatric out-patient clinic (Hospital Authority 2013b). Patients, while paying a relatively low out-of-pocket consultation fee, are giving their ‘precious time’ in order to obtain proper psychiatric care.

One would not expect a shortage of mental healthcare staff in a prosperous city like Hong Kong. However, one of the most significant challenges to local psychiatric services is actually an insufficient number of well-trained mental health professionals. According to the latest Mental Health Atlas (World Health Organization 2011), there were only 4.39 psychiatrists per 100 000 population in Hong Kong. This was well below other high-income regions such as England (17.65/100 000) and Japan (10.1/100 000). The size of the nursing workforce was also relatively small in Hong Kong: 29.15 mental health nurses per 100 000 population. Contrast this with 83.23 per 100 000 and 102.55 per 100 000 in England and Japan respectively. With only 0.58 psychologists (England: 12.84; Japan: 3.99) and 2.26 occupational therapists (England: 28.72; Japan: 4.85) per 100 000 population in Hong Kong, we are facing a shortage of other mental health professionals too. The recent introduction of new psychiatric programmes, which demand additional case managers, has intensified the staffing strain across the territory. Workforce shortage is anticipated to increase unless long-term commitment is undertaken to improve the training, recruitment and retention of mental health professionals.