Introducing family medicine in a pluralistic health care system: how patients and doctors see it

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1 Family Practice 2011; 28:49 55 doi: /fampra/cmq064 Advance Access published on 9 August 2010 Ó The Author Published by Oxford University Press. All rights reserved. For permissions, please journals.permissions@oxfordjournals.org. Introducing family medicine in a pluralistic health care system: how patients and doctors see it Y T Wun a, Tai Pong Lam b, *, K F Lam c, D Goldberg d,dktli e and K C Yip f a Family Medicine Unit, b Family Medicine Unit, c Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong, China, d Institute of Psychiatry, King s College, De Crespigny Park, London, UK, e Wonca Asia Pacific and f Department of Psychiatry, Kowloon Hospital, Hong Kong, China. *Correspondence to Tai Pong Lam, Family Medicine Unit, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong, China; tplam@hku.hk Received 17 September 2009; Revised 22 June 2010; Accepted 28 June Background. The health care systems in many countries are focused on specialist care. In those countries that have recently changed to a primary care-based system, some doctors and patients were dissatisfied with the change. Objective. To explore the opinions of the general public and the doctors on the change to a family medicine (FM)-based health care system. Methods. Qualitative study with focus groups of doctors working in different practice settings. Quantitative study with questionnaires sent to all doctors registered in Hong Kong and a telephone survey targeting the general public aged >18. Results. Doctors in the focus groups generally supported a FM-based health care system. They were concerned that there were not enough family doctors for such a system and the patients current free choice of any doctor for primary care would impede its success. Thousand six hundred and forty-seven adults took part in the telephone survey (response rate 67.6%) and 2310 doctors (22.8%) responded to the questionnaire. Nearly 95% of the general public respondents agreed to the FM system though only 66.3% of them had ever heard of the term family doctor. About 65% of the doctors supported this system but only 33% agreed that the system would work. The specialist-doctors were less supportive of mandatory referral than the non-specialists, while the public was equally divided on this issue. Conclusions. The public accepts the FM-based system but needs education on the benefits of primary health care. Direct access to the specialist would be the greatest barrier. Government involvements are essential for the reform. Keywords. Family practice, focus group, health care system, health policy, public opinion. Introduction According to the World Health Report 2008, the health care systems in many countries need reforms. 1 These health care systems are hampered by disproportionate focus on specialized curative care, fragmentation with pluralism of independent providers who collaborate poorly or unregulated commercialization of health care delivery. In the past decade, some countries reformed their health care system to focus on primary care. 2 6 There is evidence that such transformation strengthens the health care system, improves access to health care and reduces child mortality. 7 However, some studies also revealed that the change in health care system could result in low job satisfaction for doctors 8 and widespread dissatisfaction among users. 9 Thus, decision makers should consider users opinions during health service reform if they wish to build a system that is not only cost efficient but is also responsive to citizens needs, expectations, and health status. 9 The term users include both the general public and the doctors in the discussion of these papers. The health care system in Hong Kong is also pluralistic. It has a major unregulated fees-for-service private component. Currently, 70% of primary care in Hong Kong is provided by private practices of doctors (solo practitioners, group practices similar to health maintenance organizations or general outpatient clinics in private hospitals) with or without any specialty training in family medicine (FM) and 75% of outpatient consultations are paid for by out-of-pocket payments. Members of the general public could consult any doctors including specialists for any illness. The government general outpatient clinics provide primary 49

2 50 Family Practice an international journal care to citizens at a heavily subsidized rate that the fees are much lower than that of the private sector. Access to secondary care in the public system requires mandatory referral from primary care doctors or the doctors at the hospital emergency departments. In order to have a more efficient system, a recent consultative paper by the Hong Kong Government recommends the change to a health care system based on FM. 10 But what would the public and the doctors think about the change? During the years , using a combined qualitative and quantitative approach, we studied the concepts of FM held by doctors and the general public in Hong Kong. 11 The doctors focus groups discussed the proposed FM health care system for Hong Kong. The participants in the focus groups of the general public, however, were not clear about the concept of FM and were unaware of the Government s recommendation of the new system; the issue was hence not discussed. We subsequently included this health care system reform in our questionnaires for the public and the doctors with the aim to study their acceptance and the probable barriers of change. The health care system in many countries like China 12 is still hospital based and with concurrent private contributions from the patients. Information from Hong Kong could serve as a reference for policy makers and stakeholders around the world to prepare for reforming their systems, and we report our findings here for this purpose. Methods Focus group interviews of doctors To recruit doctors from primary and secondary care, we consulted the honorary teachers of the Family Medicine Unit and colleagues at the teaching hospital affiliated with the University of Hong Kong on the suitable participants for the focus group interviews. A list was then drawn up comprising doctors from different categories including generalists and specialists in private practice, doctors with postgraduate qualifications in family practice, FM vocational trainees and junior/senior specialists in hospital. Participants were purposively sampled to ensure a range of demographic variables and experience. Invitation letters were sent to them and followed by telephone contacts. Recruitment for the focus group was stopped when data saturation point was reached. A facilitator experienced with focus groups led the interviews that were audio-taped and then transcribed verbatim. The accuracy of the transcripts was checked by one of the authors (LTP) and a research assistant who had attended all the focus groups. We used the NVivo computer software and a thematic approach for the qualitative data analysis. The consistency and validity of analysis and interpretation were assessed by having the interview transcripts independently coded by LTP and a research assistant experienced in qualitative research. Questionnaire surveys We developed separate questionnaires for the doctors and the general public after the focus groups. For the doctors, the sampling population was all doctors registered with the Medical Council of Hong Kong with a local address in the year Each questionnaire was enclosed with an invitation letter explaining the project and a prepaid envelope. Up to two reminders were sent to non-respondents within 5 months. The questionnaire had been pilot tested by a group of 10 doctors of different specialties and revised before being sent out. Appendix 1 lists the specific questions on the change to a FM-based health care system in the questionnaire for the doctors. For the general public, telephone interview was chosen for data collection as >98% of the households installed domestic telephones and local calls did not incur extra charges apart from monthly rentals. The Social Sciences Research Centre of the University of Hong Kong that has extensive experience in telephone surveys carried out the interviews after training the interviewers, pilot testing the questionnaires with 70 telephone interviews and suggesting modifications of the questionnaire for clarity. A random sample of the publicly listed domestic household telephone numbers was drawn with computer software for telephone interviews. The survey was conducted in the evenings between 4:00 p.m. and 10:30 p.m. during March and April The target interviewee was the member of the family with the next earliest birthday and aged >18. Appendix 2 contains the specific questions on a FMbased health care system in the questionnaire for the general public. To estimate the sample size for the public questionnaire, we took the safe assumption that half of the population agreed/disagreed with the FM-based health care system. To ensure that the error of the estimation would be at most with 95% confidence, a sample size of at least n = 1537 was required. Results Participants Doctors focus groups. There were seven focus groups with 42 participants, 29 in private practice and 13 in public service. Specialty wise, 24 were in general/ family practice (of whom 13 with fellowships in FM) and the rest were specialists in various disciplines. The mean of years after graduation from medical school was 24.7 ±

3 Family medicine for a pluralistic health care system 51 Doctors survey. Out of valid addresses in the register of the Medical Council, 2339 (23.2%) doctors returned their questionnaires after three rounds, while 2310 (22.8%) returned questionnaires contained valid data. Of these, 1641 (71.1%) respondents were male and 667 (28.9%) female (two missing data). The mean of years after graduation was 20.4 ± Some respondents characteristics are summarizedintable1. Survey of the general public. Of the 2438 successful calls made to domestic telephones, 1647 responded to the interview, 263 dropped out during the interview and 528 refused to take part, resulting in a response rate of 67.6%. Our sample tended to have more females, middle aged and people with higher education or higher income, when compared with the population by-census in 2006 (Table 2). Comments from doctors focus groups The FM-based health care system was generally supported by the participants. Just a few opponents doubted the role of family doctors: People will classify [what kind of doctor they want to see] first. Why should I need a family doctor? My family is so small. If my son is sick, he would go to the paediatrician, my wife would go to the gynaecologist. People might have such a concept. (G3-H2, public hospital practice) Many participants of the focus groups, however, doubted whether the system was feasible. The health care delivery in Hong Kong is divided into private and public tiers. Patients can choose to see whatever [type of doctors] they want. Not until universal health system [is established], [the FM-based system] definitely [would] not work. (G6-P2, private community practice) To upgrade primary care in Hong Kong, the government must do something. But I do not see government resources for this. (G1-P3, private community practice) The most important barrier was the public s current free choice of doctors (including consulting the private specialists without referral). Whether there were enough family doctors for the system was also questioned. The idea of the general public is: I have the money and I see whichever doctor I like. They think they have the right and autonomy to do so. They like to have more control. (G7-H1, public hospital practice) If the patient has been seeing me for cardiac problems for 10 years and then one day he has a cough, he might not be able to find, or might be unwilling to see, other doctors. He comes to see me. Then I have no reason to ask him to see a family physician. I can help, so I help. (G6-P1, private community practice) The problem is: of the present four to five thousand primary care doctors in Hong Kong only a few hundred had taken training [in family medicine]. For good gatekeeping function, there must be training to a certain standard. (G1-P3, private community practice) To institute the FM-based system, public education and government involvement were deemed important. TABLE 1 Characteristics of the doctors who responded to the questionnaire Characteristics Frequency Valid percent TABLE 2 Demographic data of the telephone respondents compared to the Hong Kong by-census 2006 data This study (n = 1647), % By-census 2006 (n = a ), % Practice setting Hospital Community Missing 101 Public or private service Public Private Missing 46 Solo or group practice Solo Group Missing 369 Specialists Yes No Missing 136 Sex Male Female Age (years) > Education Primary or below Secondary Tertiary Monthly income >HKD$ b a By-census included people of all ages. b The median of monthly household income for 2006 was HKD$

4 52 Family Practice an international journal The FM-based system is good. For Hong Kong, the big problem is the inadequate knowledge about [family] doctors by the general public. When they accept that a family doctor is the frontline medical consultant, they would go to the family doctors first for all illnesses. (G3-H1, public hospital practice) To institute a FM-based system, it must be done by regulation, not fees-for-service nor free market. Any promotion or publicity would not work. If people have the choice, they would choose what they like. (G7-H1, public hospital practice) Findings of doctors survey The respondents were about equally divided on their opinions whether the system would work, and 65.4% would support it (Table 3). To allow the FM-based health care model to materialize, the majority of doctors (80.1%) considered that the public should be educated on this system, while the percentage of doctors (50.1%) opted for government intervention was the lowest. Most respondents (83.9%) agreed or strongly agreed that the freedom of choice enjoyed by local citizens to see whichever doctor they preferred was a barrier to the FM-based health care system (Table 4). Of those who stated their specialist status, 798 specialists (of 1360 or 58.7%) agreed or strongly agreed on optional referral, while 409 non-specialists (of 782 or 52.3%) did similarly; the difference was statistically significant (chi-square = 8.237, P = 0.016). However, the status of being a specialist or not was not a significant determinant of being supportive of the FM-based system (chi-square = 3.632, P = 0.458). Findings of the survey with the general public As to whether to adopt the FM-based health care system, 738 (45.1%) respondents of the public survey TABLE 3 Frequency of doctors opinions on the requisites for adopting the family medicine-based health care model and their attitudes (in descending order of combined frequencies of Likert scales 4 and 5) Opinion Likert scale a, n (%) Missing Your opinion on the model I would support it 133 (5.8%) 124 (5.4%) 533 (23.3%) 902 (39.5%) 591 (25.9%) 27 I think it will not work 224 (9.9%) 546 (24.0%) 751 (33.1%) 432 (19.0%) 319 (13.9%) 38 If Hong Kong is to adopt the model The general public should be educated on this 52 (2.3%) 75 (3.3%) 332 (14.4%) 821 (35.7%) 1022 (44.4%) 8 model More doctors need structured training in 75 (3.3%) 122 (5.3%) 400 (17.4%) 950 (41.3%) 756 (32.8%) 7 family medicine The referral system should be optional, not 193 (8.5%) 261 (11.5%) 540 (23.7%) 800 (35.2%) 481 (21.1%) 35 mandatory Doctors without training in family medicine 194 (8.4%) 237 (10.3%) 627 (27.3%) 738 (32.1%) 503 (21.9%) 11 should be formally assessed Intervention by government is mandatory 356 (15.5%) 242 (10.5%) 547 (23.8%) 569 (24.7%) 585 (25.4%) 11 a Likert scale from 1 (strongly disagree) to 5 (strongly agree); % on valid data across rows of the table. TABLE 4 Frequency of doctors opinions on the barriers of the FM-based health care system (in descending order of combined frequencies of Likert scales 4 and 5) The barriers to the above model Likert scale a, n (%) Missing Citizens have free choice to see whoever doctor 45 (2.0%) 73 (3.2%) 251 (10.9%) 766 (33.2%) 1170 (50.7%) 4 at their own expense Citizens do not have a clear family medicine 33 (1.4%) 100 (4.3%) 336 (14.6%) 786 (34.1%) 1048 (45.5%) 7 concept Citizens do not know who is a family doctor 104 (4.5%) 195 (8.5%) 522 (22.7%) 856 (37.2%) 626 (27.2%) 7 Citizens would prefer having all health matters 88 (3.8%) 223 (9.7%) 568 (24.7%) 868 (37.7%) 555 (24.1%) 8 looked after by a specialist whom they have been consulting There are not enough trained family doctors 175 (7.6%) 275 (12.0%) 590 (25.6%) 713 (31.0%) 548 (23.8%) 9 a Likert scale from 1 (strongly disagree) to 5 (strongly agree); % on valid data across rows of the table.

5 Family medicine for a pluralistic health care system 53 strongly agreed, 820 (50.1%) agreed, 15 (0.9%) disagreed and 1 (0.1%) strongly disagreed; 64 (3.9%) were neutral. Thus, an overwhelming majority (95.1%) of the respondents accepted this system (Table 5). If patients were not allowed to consult a specialist without referral by the family doctor, 165 (10.1%) of the respondents strongly agreed, 496 (30.3%) agreed, 594 (36.3%) disagreed and 147 (9.0%) strongly disagreed to such a mandatory referral; 235 (14.4%) were neutral. Overall, 40.4% accepted, while 45.3% opposed the mandatory referral. Among the respondents, 1134 (68.9%) had doctors whom they consulted regularly, 1570 (95.3%) agreed with the family doctors gatekeeping role, 764 (46.4%) knew where to find a family doctor and 478 (29.0%) agreed that there were enough family doctors in the city. Of all the respondents, 1092 (66.3%) had heard of the term family doctor and 619 (37.6%) claimed to have their own family doctors. However, 480 (29.1%) attended a specialist first on most occasions when they needed medical management; of them, 314 had specialists as their regular doctors. Comparison of the opinions on the FM-based health care system between the general public and the doctors reveals obvious incongruence (Table 5). Discussion This study investigated the opinions of the general public and the doctors on a FM-based health care system requiring mandatory referral from primary care doctors for patients to attend the specialists. Of the general public respondents, 95.1% agreed to such a system, while the doctor respondents were less positive with only 65.4% supporting this system and 33.9% agreeing that the system would work. Only 66.3% of the public respondents had ever heard of the term family doctors and 37.6% had one for their own. But 29.1% consulted the specialists most of the time when medical attention was needed and 27.7% considered the specialists as their regular doctors. These findings suggest that many people consulted the specialists for primary care problems and might even take the specialists as their family doctors. Indeed, 39.0% of the public preferred a specialist to take care of all their health care needs (Table 5). The term family doctor might not mean the same thing to the general public as to the policy makers, stakeholders or medical professionals. Thus, if the health care system is to be transformed into one which is based on FM or primary care, the public should understand the nature of the new system: what it is and why it is needed. The public should be informed of the role of family doctors, especially the benefits and cost-efficiency of primary care by family physicians and the potential harms of providing primary care by specialists Based on these factors, free choice might not be the best choice. The doctors less positive attitude towards the FMbased system is worthy of note. Studies in Kosovo 15 and Turkey 16 showed that the specialists resisted the change to the FM-based system because of reallocation of resources, competition for patients and the gatekeeper function of the family doctors. The specialists in this study, however, were similarly supportive of the FM-based system as the non-specialists though they were more likely to disagree with mandatory referral. The doctor respondents graded the public s free choice to consult any doctor as the top barrier to adopt a FM-based system. Their concern was supported by the fact that 40.4% of the public surveyed accepted, while 45.3% did not accept the mandatory referral to attend the specialists. The preference to have direct access to specialists is perhaps the biggest barrier to the TABLE 5 Comparison of opinions about the FM-based health care system between the general public and the doctors Strongly disagree or disagree, n (%) Neutral, n (%) Strongly agree or agree, n (%) Chi-square test Missing or uncertain response Agree or support the system Public 16 (1.0%) 64 (3.9%) 1558 (95.1%) P < Doctor 257 (11.3%) 533 (23.3%) 1493 (65.4%) 27 Mandatory referral to specialists Public 741 (45.3%) 235 (14.4%) 661 (40.4%) P < Doctor 1281 (56.3%) 540 (23.7%) 454 (20.0%) 35 Patients prefer the specialist for all health matters Public 536 (33.6%) 437 (27.4%) 623 (39.0%) P < Doctor 311 (13.5%) 568 (24.7%) 1423 (61.8%) 8 Patients know how to find a family doctor Public 764 (46.5%) 34 (2.1%) 844 (51.4%) P < Doctor 1482 (64.4%) 522 (22.7%) 299 (13.0%) 7 There are enough family doctors Public 759 (46.1%) 410 (24.9%) 478 (29.0%) P < Doctor 1261 (54.8%) 590 (25.6%) 450 (19.6%) 9 % on valid data across rows of the table.

6 54 Family Practice an international journal FM-based health care system. As reported elsewhere, the participants in the public focus groups of our study gave their reasons of choosing the specialist for first contact as specialist treatment for specific diseases, non-confidence in the generalists for conditions other than common diseases, appropriate management without delay and avoidance of paying two doctors for the management of one disease. 11 Direct access to specialists, however, defeats the purpose of a FM-based health care system that emphasizes the gatekeeper function of the family doctors. Mandatory referral will have to face a lot of resistance from both the public and the medical profession. Though only 40.4% of the public accepted mandatory referral, 95.3% agreed with the family doctor s gatekeeper role. The public liked to have a doctor who knew them well to plan for their specialist care and also keep a safety net for just in case situations. Assured quality in primary care and payment arrangement for referrals would minimize the public s wish for direct access. There was a wide discrepancy in opinions between the public and the doctor respondents (Table 5). The doctors might have underestimated the highly favourable expectation of the public and the public s opinions on the FM-based system. Surveys like this study are helpful to convince the medical profession and policy makers that the transformation of the health care system meets the public s needs and expectation. The countries that recently reformed their health care system into a FM-based one did so through national policies. 3 6,17 Government involvement was essential in educating the public about FM, the provision of vocational training for family doctors, enforcement of family doctors gatekeeper function, primary secondary care interface, allocation of public resources and payment arrangements. Some degree of government intervention seems to be inevitable. Though the doctors were least supportive of this, 50.1% of them still agreed or strongly agreed with government intervention and only 26.0% disagreed or strongly disagreed. Limitations The present study is limited by the uneven proportion of doctors for the questionnaire survey. Among the respondents, there were more specialists than nonspecialists. At the time of the study (early 2008), there were 4353 registered specialists among the registered doctors, and 1380 (31.7%) of them responded to our questionnaire, while 930 (16.2%) of the 5744 nonspecialists responded. The results of this study might reflect more of the specialists opinions and interests, e.g. patients free choice of doctors, and the optional referral system. On the other hand, the study was able to recruit fairly balanced responses from doctors working in hospital versus community settings and from those in private versus public sectors. These are the most common work settings for practising physicians. The response rate (22.8%) from doctors was low but common with mail surveys of doctors in Hong Kong. A similar survey to doctors with cash incentives could boost the response rate only to 19.8% in This reflects the predominant privatization of the local health care system in which doctors have little incentive for research activities. Judging from the respondents characteristics (Table 1), the non-respondents were more likely to be non-specialists in private and solo practices. We did not include the element of health care costs in our questionnaire for the public though costs would influence the choice of a system. During the time of this study, the Hong Kong Government was running a public consultation for health care financing and several options like public/private insurance were discussed. The outcomes of the consultation are still not yet available to date. The linkage of costs to a FMbased system would be premature at this stage. It would make the questionnaire complicated and even confusing to the public. Moreover, the consideration of costs would mask the assessment of the public s knowledge and attitudes towards a FM-based system. Conclusions In a locality with a pluralistic and predominantly private health care system, the proposal to change to a FM-based system was welcomed by 95.1% of the general public. However, the public did not fully understand the role of family doctors and might opt for specialists for primary care. Their opinions towards mandatory referral to attend the specialists were equally divided. Only 65.4% of the doctor respondents, specialists and non-specialist alike, supported the change; 33.9% of the doctor respondents thought that the system would work and 32.9% did not. The desire of direct access to specialists would be the most important barrier to a FM-based system. Public education on the benefits of family doctors providing primary care, the need of more family doctors and government interventions on these related issues are essential to the success of the reform. Acknowledgements We would also like to thank all those individuals who participated in the focus group interviews and telephone surveys. Declaration Funding: Central Policy Unit of the Government of the Hong Kong Special Administrative Region; Research Grants Council of the Hong Kong Special Administrative Region, China (Project No. HKU 7002-PPR-3).

7 Family medicine for a pluralistic health care system 55 Ethical approval: Institutional Review Board, Hospital Authority, Hong Kong. Conflict of interest: none. References 1 WHO Report. Primary Health Care, Now More Than Ever. Geneva: World Health Organization, Svab I. Primary health care reform in Slovenia: first results. Soc Sci Med 1995; 41: Katic M, Juresa V, Oreskovic S. Family medicine in Croatia: past, present and forthcoming challenges. Croat Med J 2004; 45: Atun RA, Menabde N, Saluvere K, Jesse M, Habicht J. Introducing a complex health innovation primary health care reforms in Estonia (multimethods evaluation). Health Policy 2006; 79: Hardison C, Fonken P, Chew T, Smith B. The emergence of family medicine in Kyrgyzstan. Fam Med 2007; 39: Günesx ED, Yaman H. Transition to family practice in Turkey. J Contin Educ Health Prof 2008; 28: Kruk ME, Porignon D, Rockers PC, Van Lerberghe W. The contribution of primary care to health and health systems in lowand middle-income countries: a critical review of major primary care initiatives. Soc Sci Med 2010; 70: Buciuniene I, Blazeviciene A, Bliudziute E. Health care reform and job satisfaction of primary health care physicians in Lithuania. BMC Fam Pract 2005; 6: Mastilica M, KuBec S. Croatian healthcare system in transition, from the perspective of users. BMJ 2005; 331: Health and Medical Development Advisory Committee. Health, Welfare and Food Bureau. Building a Healthy Tomorrow Discussion Paper on the Future Service Delivery Model for Our Health Care. Hong Kong: Food and Health Bureau, Hong Kong SAR Government, Wun YT, Lam TP, Lam KF et al. How do patients choose their doctors for primary care in a free market? J Eval Clin Pract (in press). 12 Blumenthal D, Hsiao W. Privatization and its discontents the evolving Chinese health care system. N Engl J Med 2005; 353: Franks P, Fiscella K. Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience. J Fam Pract 1998; 47: Hashem A, Chi MT, Friedman CP. Medical errors as a result of specialization. J Biomed Inform 2003; 36: Hedley RN, Maxhuni B. Development of family medicine in Kosovo. BMJ 2005; 331: Kisa S, Kisa A. National health system steps in Turkey concerns of family physician residents in Turkey regarding the proposed national family physician system. Health Care Manag (Frederick) 2006; 25: Rese A, Balabanova D, Danishevski K, McKee M, Sheaff R. Implementing general practice in Russia: getting beyond the first steps. BMJ 2005; 331: Leung GM, Ho LM, Chan MF, Johnston JM, Wong FK. The effects of cash and lottery incentives on mailed surveys to physicians: a randomized trial. J Clin Epidemiol 2002; 55: Appendix 1. Questionnaire for doctors: the specific questions on the change to a family medicine-based health care system. Q4 and Q5 are based on the following hypothetical health care model: each citizen has a family doctor, and a patient cannot consult a secondary care (private or public) specialist without referral. Q4. The barriers to the above model in Hong Kong include a) Citizens have free choice to see whoever doctor at their own expense b) There are not enough trained family doctors c) Citizens do not know who is a family doctor d) Citizens do not have a clear family medicine concept e) Citizens would prefer having all health matters looked after by a specialist whom they have been consulting Q5. If Hong Kong is to adopt the above model a) More doctors need structured training in family medicine b) Doctors without training in family medicine should be formally assessed c) The general public should be educated on this model d) Intervention by government is mandatory e) The referral system should be optional, not mandatory f) I would support it g) I think it will not work Each answer was in 5-point scales from 1 (strongly disagree) to 5 (strongly agree). Appendix 2. Questionnaire for the general public: the specific questions on the change to a family medicine-based health care system. Here is a hypothetical health care model: each citizen has a family doctor who will take care of all your health needs and problems and will refer you to see a secondary care specialist if necessary so that you do not have to seek for a specialist on your own accord. a) Do you agree to the above model? (Strongly agree, agree, neutral, disagree, don t know, refuse to answer) b) If you cannot consult a secondary care (private or public) specialist without his/her (Note: referring to the family doctor mentioned above) referral, do you agree then? (Strongly agree, agree, neutral, disagree, don t know, refuse to answer) c) Are there enough family doctors in Hong Kong? (Yes, no, don t know, refused to answer) d) Do you know how to find a family doctor when you are in need? (Yes, no, don t know, refused to answer) e) Would you prefer having all health matters looked after by a specialist whom you have been consulting? (Yes, no, don t know, refused to answer)