LETTER FROM … HONG KONG

Institutional care in Hong Kong is fragmented: 6.3% of elderly people aged 65 and over are living in long-term care institutions; of these, 55% are in private elderly homes (approximately 20 000 places) with extremely variable standards of care. Even such basic requirements as fire safety and floor space per bed may be inadequate. Publicly-funded elderly homes run by nongovernmental organizations are of better quality, but are rigidly boxed into multiple levels of care. A new category of 'nursing home' was created in 1996, theoretically to bridge the gap between social care and hospital long-stay units. Waiting for a public old age home place can take over 3 years. Family members shoulder great burdens of care, often with meagre community support. Health care for elderly patients is problematic. The private health care sector has 70% of the total outpatient market but serves less than 3% of inpatient admissions. Public health care is very much like the UK's National Health Service provision, but without a corresponding primary care structure. This top-heavy public sector is further segregated into rudimentary 'general outpatient clinics' run directly by die Department of Healdi and ever-specializing hospital services managed by the Hospital Authority, an independent publicly-funded statutory organization created in 1991 to re-vamp the region's public hospitals and their specialist outpatient clinics. Without suitable development of primary care and with the public expecting the hospital service to be both accessible and specialized, inpatient wards are overcrowded, the length of stay of patients gets shorter and clinic waiting lists become unmanageable. Ablebodied senior citizens knock on random doors, in the hope of finding a sympathetic doctor, while frail elderly patients are shuffled back and forth between acute care, non-acute care, old age homes and the community. Despite this highly stressed system, life expectancy at birth has risen to 76.0 for males and 81.5 for females. But 100 000 elderly people live on social security [just over HK$ 2000 (US$ 256.50) a month] and many of them spend as little as HK$ 24 (US$ 3) a day on food. The current social security payment is equal to approximately 20% of the median income in Hong Kong, far lower than the 30% median income equivalent that pressure groups are demanding. The prevalence of depression in Hong Kong's elders is over 20% and the elderly suicide rate is the second highest in Asia. An elderly person in Hong Kong is nearly three times as likely to commit suicide as a younger citizen.