LCQ12: Chronic Disease Co-Care Pilot Scheme
Following is a question by the Hon Chan Pui-leung and a written reply by the Secretary for Health, Professor Lo Chung-mau, in the Legislative Council today (February 19):
Question:
The Government has launched the three-year Chronic Disease Co-Care Pilot Scheme (the Scheme) from November 13 2023 to provide subsidised diabetes mellitus (DM) and hypertension (HT) screening services in the private healthcare sector to Hong Kong residents aged 45 or above with no known medical history of DM or HT. In this connection, will the Government inform this Council:
(1) of the following information on the participants since the launch of the Scheme: (i) the number of participants, as well as the distribution of their gender, age and respective District Health Centres (DHCs) and DHC Expresses and, among them, the respective numbers of participants who (ii) have completed DM and HT screening, (iii) have been diagnosed with prediabetes, DM or HT, and have entered the treatment stage, and (iv) have been arranged by their family doctors to receive a one-off internal medicine specialist consultation at the Hospital Authority through the bi-directional referral mechanism;
(2) of the following information on the participating family doctors and family doctors' service points (service points) since the launch of the Scheme: (i) the number of family doctors, (ii) the number and geographical distribution of service points, and (iii) the number of family doctors and service points that can pair participants with a family doctor at the clinic and are open for direct enrolment to the Scheme;
(3) as it is learnt that under the Scheme, the Government has recommended that family doctors should only charge participants a co-payment fee of $150 for each consultation during the treatment stage, whether the Government has compiled statistics on the respective numbers and proportions of family doctors and service points which are currently charging a co-payment fee of (i) $150 or less and (ii) over $150, as well as the highest co-payment fee;
(4) as it is learnt that there is an imbalance between family doctors and service points participating in the Scheme and participants in some districts, resulting in members of the public having to seek medical treatment in other districts or giving up on participating in the Scheme, whether the Government has measures in place to rationalise the allocation of resources, including encouraging more family doctors and service points to participate in the Scheme;
(5) as the Health Bureau announced on January 20 this year that the Scheme has introduced dedicated nurse clinic and allied health services under the district health network at over 40 service points across Hong Kong, of the number of participants who have received the additional services so far, together with a breakdown by type of service; whether it has plans to further introduce service points in the 18 districts across the territory; if so, of the details; if not, the reasons for that;
(6) given that the 2024 Policy Address has proposed to expand the Scheme to cover blood lipid testing within this year, of the specific implementation timetable and work progress concerned; whether it will further expand the Scheme to cover other tests and diseases, such as cholesterol check and osteoporosis; if so, of the details; if not, the reasons for that; and
(7) whether the various service performance indicators of the Scheme since its launch have met the Government's expectations; how the Government will step up publicity to attract more target members of the public to participate in the Scheme?
Reply:
President,
The Government launched the Chronic Disease Co-Care Pilot Scheme (CDCC Pilot Scheme) in November 2023, which is the first major initiative under the Primary Healthcare Blueprint. The Scheme provides Government-subsidised diabetes mellitus (DM) and hypertension (HT) screening and doctor consultation services to Hong Kong residents aged 45 or above with no known medical history of DM or HT, with the aim to encourage citizens to receive early screening in order to get a better understanding of their own health status, so as to achieve the objectives of early prevention, early identification and early treatment.
In consultation with the Primary Healthcare Commission (PHC Commission), the replies to the respective parts of the question raised by the Hon Chan Pui-leung are as follows:
(1) and (6) As at February 13, 2025, the number of participants in the CDCC Pilot Scheme has exceeded 100 000 (about 101 800) (see Annex I), of which around 58 700 participants have completed the screenings for DM and HT, and around 23 500 of them (i.e. nearly 40 per cent) have been diagnosed with prediabetes (note), DM or HT. The latter patients can proceed to the treatment phase and will be subsidised by the Government to continue their treatment with self-selected family doctors by shouldering certain co-payment amount under a co-payment model, and subject to their health conditions, be offered prescribed medication, and follow-up care at nurse clinics and allied health services. In addition, the Government has established a bi-directional referral mechanism with the Hospital Authority (HA) under the CDCC Pilot Scheme. Family doctors can refer participants with clinical needs to receive a one-off specialist consultation at a designated Medicine Specialist Out-patient Clinic of the HA according to clinical diagnosis and pre-defined criteria and guidelines. 29 participants have received one-off specialist consultation at the HA through the mechanism.
The Government noted that there is a higher proportion of women among participants. As at December 31, 2024, about 67 per cent of the participants were female and 33 per cent were male, with around 70 per cent of participants aged between 45 and 64. In view of the relatively low proportion of male participants, various District Health Centres / District Health Centre Expresses (collectively DHCs) are enhancing their promotional efforts focusing on men, including stepping up promotional efforts targeting at practitioners of particular industries such as transport, construction and catering, and arranging promotional activities on non-working days, especially Sundays.
The Government regularly reviews primary healthcare services and the service scope of the CDCC Pilot Scheme based on scientific evidence and resource utilisation considerations. The Government is actively planning to expand the CDCC Pilot Scheme in 2025 to cover blood lipid testing for eligible participants, allowing a more comprehensive approach to the assessment and proper management of cardiovascular disease risk factors, including the "three highs" (high blood pressure, high blood sugar and high cholesterol). Details will be announced in due course. There is currently no sufficient scientific evidence to support the recommendation that routine screening for osteoporosis among persons at average risk is effective or cost-effective. In light of this, the Government has no plan to provide osteoporosis screening services to the public at the moment. At the health management and promotion level, the DHCs will continue to organise educational activities to promote prevention of osteoporosis and osteoporotic fracture, and collaborate with different community organisations and healthcare service providers to provide information or make referrals for those interested or in need of osteoporosis services.
As mentioned in the Primary Healthcare Blueprint, local studies have shown that the healthcare system can achieve savings in healthcare expenses and reduce the burden of disease through the provision of subsidised screening and management services for DM management to suitable patients. The CDCC Pilot Scheme is a pilot scheme that encourage eligible citizens to undergo screening for DM and HT, two common chronic diseases, so that hidden patients of chronic diseases can be detected at an early stage, and their complications can be treated and prevented as early as possible, thereby reducing the need for hospitalisation. In order to further examine the effectiveness of the CDCC Pilot Scheme, the Government commissioned a local university in the first quarter of 2024 to conduct a study to assess the extent to which the objectives of the Scheme are met and the overall performance, including the service quality, effectiveness, as well as the cost-effectiveness. The Government will review the service model and operational details of the CDCC Pilot Scheme in a timely manner and make enhancements as necessary to ensure its effectiveness.
(2), (3) and (4) Family doctors are generally supportive of the CDCC Pilot Scheme. As at February 13, 2025, there are 599 family doctors (at 785 service points) participating in the CDCC Pilot Scheme, of which 182 family doctors (at 218 service points) offer direct patient enrolment at their clinics.
Of the participating service points, two-thirds (530 service points) charge co-payment at the Government-recommended consultation co-payment fee of $150 or below. The number of family doctors' service points, the distribution of districts and the range of co-payment set by the family doctors are set out in Annex II.
At present, all districts in Hong Kong have a certain number of family doctor service points. CDCC Pilot Scheme participants can, according to their own needs, choose to go to a service point near their place of residence, workplace or any other suitable service point to match with a family doctor for screening and follow-up services in a flexible manner, and hence the number of enrolled participants across districts may not align with the distribution of family doctor service points. The PHC Commission will continue to strive to increase the number of family doctor service points in various districts, with a view to providing the public with more choices and enhancing their convenience and flexibility in seeking treatment. In this connection, the PHC Commission has organised five webinars to promote and introduce the CDCC Pilot Scheme to family doctors, and actively invited family doctors/clinics, in particular, doctors who enrolled in the General Outpatient Clinic Public-Private Partnership Programme and those enlisted in the Primary Care Directory, to participate in the Scheme. The PHC Commission and the Hong Kong College of Family Physicians co-organised the World Family Doctor Day Symposium 2024 on May 18, 2024, to share and discuss with healthcare professionals the promotion of primary healthcare services in a concerted manner. The Symposium also highlighted the enhancements introduced by the Government to support family doctors in providing necessary care to CDCC Pilot Scheme participants, and successfully encouraged more doctors to join the Scheme.
Furthermore, the Government has been optimising the operational details of the Scheme by streamlining various administrative procedures and workflow, with a view to enhancing the family doctors; ease of operation of the system. Moreover, to increase the flexibility of the CDCC Pilot Scheme, starting from March 2024, members of the public can choose to directly enrol at certain participating clinics of the CDCC Pilot Scheme to pair with a family doctor in the clinic for screening. In addition, having reviewed the actual needs of participants, the Government has expanded the basic-tier drug list of the CDCC Pilot Scheme since August 2024 to increase the coverage of its basic-tier drugs from 43 items at the initial stage to 59 drug items, providing family doctors with greater flexibility in prescribing drugs according to the clinical needs of participants.
(5) In order to provide a broader scope of healthcare services with better coherence to the CDCC Pilot Scheme participants, dedicated nurse clinic and allied health (including optometrists, physiotherapists and dietitians) services were introduced on January 20, 2025. Nurse clinic and allied health services are referral-based. Family doctors or the DHCs will make referrals based on the health needs of CDCC Pilot Scheme participants for suitable treatment and follow-up care. Nurse clinics are generally able to handle most cases effectively and their service points cover Hong Kong Island, Kowloon and the New Territories, whereas allied health services mainly focus on patients with specific clinical needs or complex medical conditions, and thus it is not necessary to establish service points in all districts. In less than a month since the introduction of the relevant services, 47 CDCC Pilot Scheme participants have already made appointments for relevant services, of which 33 have received services (see Annex III).
The dedicated nurse clinic and allied health services will be rolled out in phases, with the first phase to provide services to CDCC Pilot Scheme participants. Other members of the DHCs who are not participating in the CDCC Pilot Scheme will receive dedicated nurse clinic and allied health services under a co-payment model in the next phase, with details to be announced later.
(7) Since the launch of the CDCC Pilot Scheme, the Government has promoted the CDCC Pilot Scheme through various channels, among which the DHCs play an important role. In addition to inviting existing eligible members to participate in the CDCC Pilot Scheme, the DHCs also organise large-scale promotional activities in respective districts and strengthen connection with the public through community outreach activities, mobile outreach vehicles and promotional booths in community complexes. The DHCs have been actively co-operating with community service partners, such as the District Services and Community Care Teams to organise community activities to recruit eligible individuals to become Scheme participants.
At the same time, the Government has also been carrying out other forms of publicity activities to promote the CDCC Pilot Scheme through various television and media channels, and providing the public and healthcare service providers with latest information of the CDCC Pilot Scheme through various communication platforms (such as website, telephone hotline, posters and brochures, electronic newsletters and online briefings).
Note: Prediabetes with glycated haemoglobin level of 6.0 to 6.4 per cent or fasting plasma glucose level of 6.1 to 6.9 mmol/L.