Clinical liability arises when a medical practitioner fails to meet the standard of reasonable medical care.1 Most medical malpractice litigation is pursued under the tort of negligence (civil cases). The burden of proof is ‘on the balance of probabilities’ in civil cases. In criminal cases, the burden of proof is ‘beyond reasonable doubt’, and the prosecution bears the burden of proof. Convictions for criminal charges such as gross negligence manslaughter (GNM) require a higher degree of wrongfulness.

A recent book chapter highlighted the tension and fears among healthcare professionals with rising the increasing number of high-profile GNM cases, coupled with the perception of arbitrary and inconsistent approaches to GNM investigation and prosecution in the United Kingdom2 resulting in a rapid policy review on GNM in healthcare.3 The review panel emphasised that healthcare professionals could not be, or appear to be, above the law. However, the complexities of modern healthcare and the stressful clinical environment must be taken into consideration when deciding whether to pursue a GNM investigation.

In 2018, Leung4 reviewed key medical manslaughter cases from the previous decade: Sellu,5 Bawa-Gaba,6 and DR Group.7 In Sellu,5 the surgeon was held in high regard by his peers and patients, and the penalty was considered unjustifiable and disproportionate. In Bawa-Gaba,6 there was criticism for failing to give due consideration to system factors.8 In DR Group,7 a retrial of one of the defendants, Dr Mak, was ongoing at the time of the 2018 review. The findings of two reviews (by the United Kingdom Government3 and the General Medical Council9) led to a perception among healthcare professionals that the legal tests for GNM were inconsistently applied.2 Thus, there is a need to review the judgements in the retrial of Dr Mak10 and another case involving a doctor convicted of GNM, Dr Kwan,11 in the context of some key historical cases and published literature.

Before the retrial of Dr Mak, the defendant doctor appealed on the question of requirement of the prosecution to prove the culpability of the defendant’s state of mind that she was subjectively aware of the obvious and serious risk of death to the deceased.12 The Court of Final Appeal unanimously dismissed the appeal that only application of the objective standard of reasonableness, as referred in the last element of the offence in R v Adomako,13 is needed with no additional requirement to prove the defendant’s subjective aware of an obvious and serious risk of death.12

In Adomako,13 an anaesthetist in charge of a patient during eye surgery failed to notice or respond to obvious signs of oxygen tube disconnection, and the patient died. The jury convicted the anaesthetist of GNM. The evidence13 indicated that 4.5 minutes would have elapsed between the disconnection and sounding of the alarm; the anaesthetist responded in various ways but did not check the oxygen tube connection. One expert witness stated that a competent anaesthetist should have recognised the disconnection within 15 seconds because the patient’s blood pressure and pulse had decreased, and the patient’s chest was not moving. Another expert witness described the standard of care as ‘abysmal’ (extremely bad). The anaesthetist’s conviction of GNM was upheld by the House of Lords on appeal.13 Lord Mackay LC set the following tests for a conviction of GNM13:

Had the defendant breached the duty of care towards the victim who had died?

If yes, whether the breach of duty had caused death?

If so, the jury needed to go on to consider whether that breach of duty should be characterised as gross negligence and therefore as a crime.

The jury would then have to consider the extent to which the defendant’s conduct departed from the proper standard of care constituting a risk of death to the patient, was such that it should be judged criminal.

The jury question was whether the conduct of the defendant was so bad in all the circumstances as to amount in their judgement to a criminal act.

There was an argument about circularity because the jury was asked to define whether an offence had been committed; the jury’s task is to determine the facts, then apply the law. Lord Mackay was aware of the element of circularity and he did not believe that it would be fatal as the test being correct to determine how far the conduct should depart from the accepted standard to be characterised as criminal. The judgement of the Court of Final Appeal regarding Dr Mak stated that the test is not circular and there is no abdication of the judge’s role in defining the offence for the jury.12 Juries are assisted by expert evidence when considering difficult questions, and it is not unusual for juries to perform an evaluative function.12 In R v Misra,14 Judge LJ pointed out that the jury would be asked difficult questions, such as whether a defendant had acted dishonestly by reference to the contemporary standard, or when charged on dangerous driving causing death, whether the standard of driving fell far below the standard to be expected as a competent driver.15

In Misra,15 the doctor was convicted of GNM when their patient became infected with Staphylococcus aureus after surgery and did not receive the necessary treatment. The defendant doctor appealed on the basis that the test for gross negligence presented to the jury was circular and unclear. The appeal was dismissed; the jury’s determination of ‘gross negligence’ was regarded as a question of fact, rather than a question of law. The Lord Justice Judge wrote that there was a failure to appreciate the patient’s serious illness, including the classic signs of infection (elevated temperature, rapid pulse, and lowered blood pressure). The mistakes made were elementary.16

In the retrial of Dr Mak,10 the defendant doctor was found guilty of GNM by the jury. The judge was satisfied that the jury must have found the defendant doctor in breach of her duty to the deceased and it was reasonably foreseeable that the breach of that duty giving rise to a serious and obvious risk of death and indeed caused the death. The jury must have also been satisfied that the circumstances of the breach were truly exceptionally bad and so reprehensible to justify criminal punishment.

In Dr Kwan,13 the patient attended for liposuction procedure. The patient was infused with the combination of sedative drugs at the start of the procedure and she was deeply sedated and unconscious. She was attached to the Mindray machine during the procedure and the device alarmed throughout the procedure indicating that there was a problem with patient’s vital signs. The alarm was ignored and silenced each time by one of the assistants. After the completion of the procedure, the defendant doctor left leaving the patients under the care of medically untrained assistants while the patient was still unconscious. The defendant doctor was called back by her assistants when the patient’s condition had deteriorated. The defendant doctor called for help but did not provide resuscitation of basic life support.

The jury’s verdict was that the defendant’s failures fell far below the standard of a competent doctor.13 The inactions and actions of the defendant substantially caused the death of the patient. A reasonably competent doctor would have foreseen that the breach of her duties gave rise to a serious and obvious risk of death and her breach was so truly exceptionally bad and so reprehensible.

In R v Rose,17 the defendant optometrist negligently failed to examine the retinas of a child and thus did not identify papilledema; consequently, hydrocephalus in the child was not diagnosed or treated, and the child died a few months later. The Court of Appeal held that, in failing to examine the eye at all, the optometrist would not have been aware of ‘a serious and obvious risk of death’; thus, Rose was considered simply negligent. Conversely, in R v Winterton,18 the defendant construction manager was convicted of manslaughter when a trench collapsed on a labourer, causing that labourer’s death. The Court of Appeal held that the obvious and serious risk of death caused by the trench should have been apparent to Winterton.

An article by Robson et al19 offers the criticism that current GNM tests are not particularly concerned with the context in which a negative event occurs; they are solely focused on evaluating responsibility for specific acts of misconduct. Importantly, Robson et al19 address the element of culpability necessary for conduct to be considered criminal, particularly with respect to distinguishing errors from violations. Errors constitute instances in which ‘one tries to do the right thing but actually does the wrong thing’; violations constitute instances that involve intentional deviations ‘from those practices deemed necessary to maintain the safe operation of a potentially hazardous system’.20 Robson et al19 argue that a negligent doctor should not be criminally liable for a momentary lapse of concentration or an instance of inattention that involved an error in judgement.

Although current law only applies the objective standard of reasonableness, case law has established the key elements that can be used to determine whether negligent act of medical practitioner would be alleged GNM:

gross departure from expected standard of care;

ignoring reasonable foreseeable obvious and/or serious risks;

failing to take actions to allow the risks continuing to endanger patient’s life;

the acts of medical practitioners disregard the life of the patient; and

the circumstances of the breach of duty (in Adomako all circumstances were emphasised) should have been truly exceptionally bad, ie, no reasonable doctor would have done.

It is important that precise direction is given to jury to consider the facts whether the standard of care has really fallen far below the standard and exceptionally bad taken account of the circumstances. The jury must consider whether the defendant doctor should have been aware of reasonably foreseeable obvious and serious risks, but failed to take action. Recent editorial has highlighted the important role of expert opinion in triggering an investigation and determination of a case for prosecution.21 Juries rely upon high-quality expert opinions when making factual determinations regarding whether a medical practitioner’s conduct constitutes GNM.

A criminal conviction has serious and devastating consequences; thus, many countries (both common law and civil law jurisdictions) uphold the doctrine of ‘Presumption of Innocence’. For GNM in clinical context, the facts must be accurately dissected and assessed by competent experts; each element of the offence must be proven beyond reasonable doubt to support a conviction of GNM.

The author was solely responsible for drafting of the manuscript, approved the final version for publication, and takes responsibility for its accuracy and integrity.

This editorial has received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The author has disclosed no conflicts of interest. The opinions expressed in this article reflect the views of the author, not the institutions with which he is affiliated.

1. Lee A. Clinical liability in Hong Kong: revisiting duty and standard of care. In: Raposo VL, Beran RG, editors. Medical Liability in Asia and Australasia (Ius Gentium: Comparative Perspectives on Law and Justice, 94). Singapore: Springer; 2022: 41-60. Crossref

2. Lee DW, Tong KW. What constitutes negligence and gross negligence manslaughter? In: Chiu JS, Lee A, Tong KW, editors. Healthcare Law and Ethics: Principles & Practices. Hong Kong: City University of Hong Kong Press; 2023: 112-52.

3. Department of Health and Social Care, United Kingdom. Gross negligence manslaughter in healthcare. The report of a rapid policy review. Jun 2018. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/717946/Williams_Report.pdf. Accessed 17 Mar 2023.

4. Leung GK. Medical manslaughter in Hong Kong—how, why, and why not? Hong Kong Med J 2018;24:384-90. Crossref

5. David Sellu v R. [2016] EWCA Crim 1716

6. R v Hadiza Bawa-Garba [2016] EWCA Crim 1841

7. HKSAR v Chow Heung Wing Stephen & Ors [2018] HKCFI 60

8. Cohen D. Back to blame: the Bawa-Garba case and the patient safety agenda. BMJ 2017;359:j5534. Crossref

9. General Medical Council. Independent review of gross negligence manslaughter and culpable homicide. 2019. Available from: https://www.gmc-uk.org/-/media/documents/independent-review-of-gross-negligence-manslaughter-and-culpable-homicide---final-report_pd-78716610.pdf. Accessed 22 Feb 2023.

10. HKSAR v Mak Wan Ling [2020] HKCFI 3069

11. HKSAR v Dr. Kwan Hau-chi, Vanessa [2021] HCCC 2000/2018, [2021] HKCFI 2978

12. HKSAR v Mak Wan Ling [2019] HKCFA 37

13. R v Adomako [1994] 3 WLR 288 House of Lords

14. R v Misra [2005] 1 Cr App R 21

15. R v Misra [2005] 1 Cr App R 21 at §63

16. R v Misra and Srivastava [2005] 1 Cr App R 328

17. R v Rose [2017] EWCA Crim 1168

18. R v Winterton (Andrew) [2018] EWCA Crim 2435

19. Robson M, Maskill J, Brookbanks W. Doctors are aggrieved—should they be? Gross negligence manslaughter and the culpable doctor. J Criminal Law 2020;84:312-40. Crossref

20. Merry A, Brookbanks W. Violations. In: Merry A, Brookbanks W. Merry and McCall Smith’s Errors, Medicine and the Law. 2nd ed. Cambridge: Cambridge University Press; 2017: 141-82. Crossref

21. Leung GK. Medical manslaughter in Hong Kong: what now? Hong Kong Med J 2023;29:4-5.Crossref

The liver is a common metastatic site for colorectal, lung, and breast cancers. In addition to palliative chemotherapy, there have been advances in therapeutic options for liver-directed therapies, which can prolong patient survival and may be curative. Since the 1960s, hepatic metastasectomy has provided a glimmer of hope to patients with cancer.1 A study in the 1990s revealed a 5-year survival rate of 37% in colorectal patients who underwent liver resection for treatment of one to three liver metastases.2 Improvements in surgical technique, patient selection, and systemic treatment have allowed liver resection to achieve 5-year survival rates of >50%, compared with approximately 5% for patients who receive palliative chemotherapy alone.3

Currently, resectability is defined as the ability to perform complete (R0) resection with adequate preservation of the future liver remnant. The presence of unresectable extrahepatic disease remains a contraindication to liver surgery. For patients who are not good surgical candidates, attractive options include non-surgical liver-directed therapies such as stereotactic body radiotherapy (SBRT), selective internal radiation therapy, transarterial chemoembolisation, hepatic arterial infusion therapy, and radiofrequency ablation.4

Over the years, the role of SBRT in the management of liver metastases has considerably evolved; it is now considered safe and effective therapy. Additionally, SBRT provides excellent local control of liver metastases and carries a comparatively low risk of treatment-related toxicity.5

Patient selection for SBRT is important. Desirable patient characteristics include good performance status with limited disease burden and adequate non-irradiated liver reserve (≥700 cc). Moreover, there is a need for caution regarding the irradiation of liver metastases adjacent to the luminal gastrointestinal tract, which could result in bowel perforation.6 For better outcomes, desirable patient characteristics include limited extrahepatic disease, lesion size ≤3 cm, and fewer than three hepatic lesions.4 Stereotactic body radiotherapy generally provides favourable local control of hepatic metastases; most authors report achieving approximately 80% local control at 2 years if higher biologically equivalent doses are delivered.5 6 7 8

Stereotactic body radiotherapy is administered using a linear accelerator, which precisely delivers high-dose ionising radiation in the form of mega-voltage photons; the treatment is administered in one to five fractions within 14 elapsed days. The dose closely conforms to the target, leading to rapid dose fall-off outside of the target. Usually, SBRT doses are prescribed to the 80% isodose line, which covers at least 95% of the planned target volume.8 Nevertheless, irradiation of the liver can result in radiotherapy-induced liver diseases, which may lead to liver failure and even death, particularly in cases of re-irradiation. In terms of radiobiology, the liver obeys the parallel architecture model; thus, the risk of radiotherapy-induced liver disease is generally proportional to the mean dose of radiation delivered to normal liver tissue. This risk can be minimised by ensuring high accuracy in respiratory motion management via four-dimensional computed tomography, in combination with active breathing control, abdominal compression, or respiratory gating. On-boarding imaging must be conducted before SBRT to allow for the immediate correction of patient positioning.9

In this issue of the Hong Kong Medical Journal, Choi et al10 conducted a retrospective study of 31 patients with liver metastases treated by SBRT between January 2012 and December 2017. Actuarial in-field local control rates at 1, 2, and 3 years after SBRT were 93%, 55%, and 42%, respectively. The median survival was 32.9 months; the 1-year, 2-year, and 3-year actuarial survival rates were 89.6%, 57.1%, and 46.2%, respectively. The treatment was well-tolerated. The authors concluded that patients receiving post-SBRT chemotherapy had significantly longer overall survival, highlighting the need for multimodal treatment with effective systemic therapy, rather than monotherapy with either method alone. This real-world evidence supports the evolving role of SBRT in the management of liver metastases in Hong Kong. There is increasing clinical interest in the use of SBRT to manage liver metastases; this new direction is accompanied by many challenges and questions. Future prospective studies may shed light on the most effective SBRT treatment sequence, key factors concerning patient selection, and optimal systemic treatment (in combination with immunotherapy and chemotherapy) for patients with liver metastasis.

The author was solely responsible for drafting of the manuscript, approved the final version for publication, and takes responsibility for its accuracy and integrity.

This editorial has received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The author has disclosed no conflicts of interest.

1. Scheele J, Stang R, Altendorf-Hofmann A, Paul M. Resection of colorectal liver metastases. World J Surg 1995;19:59-71. Crossref

2. Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH. Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann Surg 1999;230:309-18. Crossref

3. House MG, Ito H, Gönen M, et al. Survival after hepatic resection for metastatic colorectal cancer: trends in outcomes for 1,600 patients during two decades at a single institution. J Am Coll Surg 2010;210:744-52. Crossref

4. Cervantes A, Adam R, Roselló S, et al. Metastatic colorectal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2023;34:10-32. Crossref

5. Chang DT, Swaminath A, Kozak M, et al. Stereotactic body radiotherapy for colorectal liver metastases: a pooled analysis. Cancer 2011;117:4060-9. Crossref

6. Das IJ, Dawes SL, Dominello MM, et al. Quality and safety considerations in stereotactic radiosurgery and stereotactic body radiation therapy: an ASTRO safety white paper update. Pract Radiat Oncol 2022;12:e253-68. Crossref

7. Petrelli F, Comito T, Barni S, et al. Stereotactic body radiotherapy for colorectal cancer liver metastases: a systematic review. Radiother Oncol 2018;129:427-34. Crossref

8. John RG, Ho F, Appalanaido GK, et al. Can radiotherapy finally “go live” in the management of liver metastases? Hepatoma Res 2020;6:56. Crossref

9. McPartlin A, Swaminath A, Wang R, et al. Long-term outcomes of phase 1 and 2 studies of SBRT for hepatic colorectal metastases. Int J Radiat Oncol Biol Phys 2017;99:388-95. Crossref

10. Choi CK, Ho CH, Wong MY, et al. Efficacy, toxicities, and prognostic factors of stereotactic body radiotherapy for unresectable liver metastases. Hong Kong Med J 2023;29:105-11. Crossref

The Hong Kong Medical Journal (HKMJ) was first indexed on MEDLINE in 2000 and has developed over the years to now have a Journal Impact Factor of 3.125 (Clarivate, 2022). The HKMJ is an important forum for the dissemination of both local and international medical research and, with the support of the Hong Kong Academy of Medicine and the Hong Kong Medical Association, is freely accessible online with no publication charges. The HKMJ constantly evolves, and the Editorial Board take strategic decisions to keep the content contemporary and interesting for our readers.

Healthcare changes rapidly. New drugs, techniques and guidelines can be bewildering. Perspectives exhibit a new and original viewpoint on available issues, basic concepts, or widespread notions on a particular topic, suggest and encourage a new speculation, or discuss the implications of a newly implemented innovation. Perspectives may focus on common advances and coming directions on a topic, and may include unique information along with personal experience and point of view. Perspectives can be just that or an opinion or commentary. Similar to the Perspective section of the New England Journal of Medicine, this new article type for HKMJ will cover timely and relevant topics in Medicine and Healthcare presented in a brief manner.1 These are scholarly articles which denote a personalised point of view or a new perspective on a specific topic. Perspectives may also be narrative reviews of the literature discussing recent developments in a specific topic or guiding practice for clinicians as our new Perspective article type. Although these articles do not amount to unique research, they can be clinically elucidating and still add value to the scientific literature, encourage discourse, and improve the overall impact of the journal.

Perspective articles mainly constitute an opinion which exhibits the author’s viewpoint on the strengths and weaknesses of a speculation or scientific theory and ought to be constructive criticism backed by evidence intended to promote scientific dialogue that challenges the current state of knowledge in a specific field. The editors will also consider perspective articles discussing timely clinical or health topics, or research studies published elsewhere. The editors request, however, that authors do not principally aim to discuss their own work and try to be balanced in their opinions.

Commentaries can also be considered under this banner but tend to be shorter (≤1200 words) and should draw attention to or critique a previously released article, book, report or guideline, using anecdotal evidence or the author’s personal experience to highlight points of wider relevance to the field.

Perspective articles should be generally <2000 words and usually include one figure or table, and will be peer reviewed.

While editors may invite such articles from reviewers or experts in the field, authors should consider writing a Perspective or Commentary in situations where: the topic is of broad concern to a wider audience or to the scholarly community in general; the author wishes to present opinions and ideas or describe an innovation that has not yet been broadly implemented; or the author wishes to provide an in-depth discussion of a topic or literature review that would be too lengthy for a commentary but does not amount to a systematic review.

Whether you are writing a Perspective detailing an innovation, or providing your opinions or ideas from a particular perspective, decide on the message you wish to express and organise your thoughts logically. Perspectives are still scholarly articles, although they denote a personalised point of view or a new perspective about available research; references, figures and tables should be used sparingly to support key facts. A number of journals have adopted similar article types and we feel that Perspectives is an innovation that will prove very popular with readers. Guidelines on format and presentation are now available in our Guide for Authors (https://www.hkamedtrack.org/hkmj/guide_for_author). What are you waiting for?

The author contributed to the editorial, approved the final version for publication, and takes responsibility for its accuracy and integrity.

The author has declared no conflict of interest.

1. Article types. The New England Journal of Medicine. Available from: https://www.nejm.org/author-center/article-types. Accessed 13 Jan 2023.

In Hong Kong, it is government policy that no one is denied adequate medical care due to a lack of means, making Hong Kong a proud provider of almost universal access to medical services. Nonetheless, these medical services provided by the Hospital Authority mostly involve specialist care that eventually dominates a 'treatment-based' patient care system and plays down preventive care. With a rapidly ageing population1 and escalating burden of chronic diseases, the impact of complicated disease is compounded by neglect of care for patients who are otherwise well but at an early stage of disease. This results in increasingly long waiting times for 'routine' specialist out-patient care.2

As evidenced by Hong Kong’s Domestic Health Accounts in 2019/20, only around 17% of the total public current health expenditure was spent on primary healthcare, with the remaining 83% spent on secondary and tertiary healthcare services.3 This implies that most individuals will not undergo individual health assessments because they are rarely able to obtain routine individualised preventive care advice from doctors about issues such as vaccination scheduling, cancer screening or chronic disease screening.4

Data from the Hong Kong Population Health Survey 2014/15 revealed that 54.1% and 47.5% of patients with diabetes mellitus (DM) and hypertension, respectively, were unaware of their condition prior to the health examination that formed part of the survey.5 Even worse, patients known to be pre-diabetic did not receive the care that may have prevented their progression to DM (an annual conversion rate of approximately 5-10%).6 7 With no alternative, public hospitals must care for these patients, with approximately 40 000 per year newly diagnosed and referred.8 The dilemma is how to tackle the challenge of maintaining public health with minimal intervention in a city where the number of patients with chronic disease is projected to reach 3 million by 2039.9

Currently, Hong Kong has an underdeveloped primary healthcare system with the private sector providing around 70% of all services.10 Compared with 11 developed countries, Hong Kong lacks a mature family doctor network, a core component of continuous care provision that can improve chronic disease management and prevention.11 The concept of 'family doctor for all' is one of the key visions of the Primary Healthcare Blueprint issued by the Government of the Hong Kong Special Administrative Region in December 2022. The plan is to formalise and link the Primary Care Directory and subsidised services, not only for Elderly Health Care Vouchers, vaccination and cancer screening but also chronic diseases, with matched family doctors.

In 2023, the Health Bureau will pilot the Chronic Disease Co-Care Scheme announced in the Policy Address 2022. The objective is to make use of the community network to improve (1) screening, (2) diagnosis of pre-diabetes, early DM and hypertension, and to (3) match patients with a family doctor listed in the Primary Care Directory. There is evidence that for individuals with early-stage or asymptomatic chronic disease, lifestyle modification and early medical intervention are essential.12 Therefore, the programme will coordinate and subsidise both local and professional support for patients to receive holistic care and lifestyle interventions from family doctors and District Health Centres. The proposed packages will encourage individuals to build a long-term relationship with a self-selected family doctor supported by a community coordinator.

A new statutory body to be established in 2024, the Primary Healthcare Commission, will develop district-based healthcare and drive the 'family doctor for all' policy in an attempt to shift the focus of patient care towards prevention by increasing public funding. Through coordination and networking, the future healthcare model will provide public access to screening, health planning, community care and individual advice/intervention by a family doctor. This will be achieved through: (1) consolidation of existing services provided by the Department of Health, (2) purchased private services, (3) enhanced training in family medicine, (4) coordination of community networks, and (5) better governance including bi-directional referrals between primary and secondary care. Setting up of clinical standards and performance monitoring will be core functions to build public confidence in the purchased or network services. The Primary Care Register for family doctors will be formalised and structured for the general public under a legal framework. Furthermore, through the Electronic Health Record Sharing System and the eHealth App, more initiatives rolled out via digital healthcare will increase connections and networks available within the community. With a mature family doctor system, more subsidised and convenient disease prevention programmes can be initiated to improve public health.

Hong Kong has a dual track medical system, but 'treatment-based' healthcare is not sustainable in the provision of quality care. The Primary Healthcare Blueprint aims to steer our future multidimensional development to include a prevention centric system. The reform requires the full support of our professionals who can share common goals in building trust between professionals and the community, as well as pursuing timely interventions for people of all ages within a strong primary healthcare system.

Both authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

Both authors have declared no conflict of interest.

1. Census and Statistics Department, Hong Kong SAR Government. Hong Kong Population Projections 2020-2069, 2020 edition. Available from: https://www.censtatd.gov.hk/hkstat/sub/sp190.jsp?productCode=B1120015. Accessed 23 Dec 2022.

2. Hong Kong SAR Government press release. LCQ7: Specialist out-patient services of Hospital Authority. 21 July 2021. Available from: https://www.info.gov.hk/gia/general/202107/21/P2021072100563.htm. Accessed 23 Dec 2022.

3. Health Bureau, Hong Kong SAR Government. Hong Kong’s Domestic Health Accounts 2019/20. Available from: https://www.healthbureau.gov.hk/statistics/en/dha.htm. Accessed 23 Dec 2022.

4. Tam DY, Lo YY, Tsui W. Knowledge, practices and expectations of preventive care: a qualitative study of patients attending government general outpatient clinics in Hong Kong. BMC Fam Pract 2018;19:58. Crossref

5. Surveillance and Epidemiology Branch, Centre for Health Protection, Department of Health, Hong Kong SAR Government. Report of Population Health Survey 2014/15. 2017. Available from: https://www.chp.gov.hk/en/static/51256.html. Accessed 23 Dec 2022.

6. Tabák AG, Herder C, Rathmann W, Brunner EJ, Kivimäki M. Prediabetes: a high-risk state for diabetes development. Lancet 2012;379:2279-90. Crossref

7. Li G, Zhang P, Wang J, et al. The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study. Lancet 2008;371:1783-9. Crossref

8. Quality Assurance Sub-committee of Central Committee on Diabetic Service. Hospital Authority. Hospital Authority Diabetes Mellitus Care Report 2019/20. 2020. Available from: https://www.ha.org.hk/haho/ho/icp/HA_DM_Care_Report1920_en_txt.pdf. Accessed 23 Dec 2022.

9. Hospital Authority. Hospital Authority Strategic Plan 2022-2027. 2021. Available from: https://www.ha.org.hk/haho/ho/ap/HA_StrategicPlan2022-2027_Eng_211216_1.pdf. Accessed 27 Dec 2022.

10. Our Hong Kong Foundation. Strategic Purchasing: Enabling Health for All. Dec 2021. Available from: https://ourhkfoundation.org.hk/sites/default/files/media/pdf/20211214_OHKF_Health_Finance_Research_Report_E.pdf. Accessed 27 Dec 2022.

11. Wong SY, Zou D, Chung RY, et al. Regular source of care for the elderly: a cross-national comparative study of Hong Kong with 11 developed countries. J Am Med Dir Assoc 2017;18:807.e1-8. Crossref

12. Haw JS, Galaviz KI, Straus AN, et al. Long-term sustainability of diabetes prevention approaches: a systematic review and meta-analysis of randomized clinical trials. JAMA Intern Med 2017;177:1808-17. Crossref

Antimicrobial resistance (AMR) has been declared one of the top ten global public health threats facing humanity by the World Health Organization (WHO) in 2019.1 The WHO has estimated that, by 2050, the number of deaths attributed to AMR will be as high as 10 million each year, exceeding those caused by cancer (8.2 million).2 The coronavirus disease 2019 (COVID-19) pandemic has exacerbated the AMR situation globally. In 2020, the Centers for Disease Control and Prevention of the United States reported more cases of carbapenem-resistant Acinetobacter (increased by 78%), antifungal-resistant Candida auris (increased by 60%), and carbapenem-resistant Enterobacterales (increased by 35%) than in 2019, possibly due to more and sicker patients during the pandemic who required more frequent and longer use of catheters and ventilators, personal protective equipment and laboratory supply challenges, fewer healthcare staff, and longer lengths of stay.3 Outbreaks of multidrug-resistant organisms, including carbapenem-resistant Acinetobacter baumannii,4 5 C auris6 and Enterobacterales,7 as well as vancomycin-resistant Enterococcus,8 9 have been reported in healthcare facilities. In a systematic review that identified 17 outbreaks during the COVID-19 pandemic caused mainly by carbapenem-resistant Acinetobacter baumannii and C auris, inadequate personal protective equipment or hand hygiene adherence, personal protective equipment shortage, and high antibiotic use were the most commonly reported modifiable factors contributing to the outbreaks.10 In some countries, antimicrobial stewardship programmes in hospitals were adversely affected or even suspended.11 12 Hong Kong is not immune to these challenges, and substantial resource have been diverted to tackle the COVID-19 pandemic.

Despite these constraints, considerable progress has been made in Hong Kong, according to directives as described in the Hong Kong Strategy and Action Plan on Antimicrobial Resistance (2017-2022).13 The AMR Information System was established in October 2021 to collate, analyse, and report data from various departments of the Hong Kong SAR Government and the Hospital Authority. This system provides well-organised and transparent access to surveillance data on the human side covering AMR and antimicrobial use (AMU). Antimicrobial resistance and AMU involving food animals are also now included in a regular surveillance programme, and a long-term food surveillance system on AMR has been established. Enhanced regulatory measures against the illegal sale of antimicrobials, health promotional activities, and collaboration between healthcare providers and community partners to advocate appropriate use of antimicrobials have been effective. The percentage of total supply of antibiotics to community pharmacies gradually decreased from around 18.5% in 2016 to 5.6% in 2021. Under the Antibiotic Stewardship Programme in Primary Care initiative, new guidance notes and patient information sheets on seven common infections have been developed to drive appropriate antibiotic use by primary care doctors. Coupled with antimicrobial stewardship programmes implemented in hospitals, the proportion of the total antimicrobial supply classified as the “Access” group under WHO classification (ie, those showing lower resistance potential than antibiotics in the other groups) reached 61.9% in 2020 and 65.8% in 2021 in Hong Kong, above the 60% target set by the WHO. Data from the Hospital Authority in 2021 reflected that 94.5% use of two broad spectrum antibiotics, namely piperacillin/tazobactam and meropenem, were found to be appropriately used in medical, surgical and orthopaedic and traumatology specialty of acute hospitals.14

The Hong Kong SAR Government is also tackling AMR on other fronts. For animal health, a policy is being prepared for “veterinary prescription-only medication supply”.14 To reduce the incidence of infection, infection prevention and control training is in place, with over 30 000 attendances per year in the human health sector and 6000 in the food sector. The Department of Health has also been offering free seasonal influenza vaccination and pneumococcal vaccination to eligible target groups, which helps reduce potential complications from these diseases, such as secondary bacterial infections and AMU. Under the “One Health” framework, the Department of Health, the Agriculture, Fisheries and Conservation Department, and the Food and Environmental Hygiene Department have joined together to launch publicity activities to echo the annual World Antibiotic Awareness Week to promote proper use of antibiotics. To encourage research, AMR has been included as one of the thematic priorities in the open call for investigator-initiated projects under the Health and Medical Research Fund, and 33 related projects have been funded in the 2017 to 2020 round of open call applications.

Nevertheless, many challenges to further improve the AMR situation remain. A sustained high rate of methicillin-resistant Staphylococcus aureus bacteraemia was detected after 48 hours of admission in public hospitals in the past few years. Data reported to the Centre for Health Protection indicate that the number of cases of carbapenemase-producing Enterobacteriaceae discharged to residential care homes for the elderly has been doubled from 242 cases in 2019 to 526 cases in 2021. Since the first case of C auris, an emerging multidrug-resistant fungus, reported in Hong Kong in July 2019, more cases and outbreaks in public hospitals have been reported.15 16 Despite a reduction of AMU among community pharmacies and general practitioners in 2020 and 2021, it is possible for rebound of respiratory illnesses and resurge of AMU in these settings after relaxation of public health measures for COVID-19. Health promotion on AMR is still needed: in a survey of the general public, 54.0% of respondents mistakenly identified cold and flu as treatable with antibiotics.17 Moreover, comprehensive data on AMU and AMR among general practitioners are lacking. There is also limited scientific knowledge on the role of the environment in the evolution of AMR.

In his Policy Address on 19 October 2022, the Chief Executive of Hong Kong pledged to promulgate a new plan on AMR for the next 5 years. To tackle this public health threat and address challenges ahead, Hong Kong Strategy and Action Plan on Antimicrobial Resistance (2023-2027)14 adopts six key policy areas: strengthen knowledge through surveillance and research; optimise use of antimicrobials in humans and animals; reduce incidence of infection through effective sanitation, hygiene and prevention measures; improve awareness and understanding of AMR through effective communication, education and training; promote research on AMR; and strengthen partnerships and foster engagement of relevant stakeholders. Among the 21 objectives in the Action Plan, five are identified as priority interventions: surveillance and control of AMR in ready-to-eat food; strengthening regulation of record keeping for prescription-only antimicrobials in community pharmacies; enhancement of antimicrobial stewardship programme in public hospitals; a territory-wide decolonisation programme for multidrug-resistant organism in residential care homes for the elderly; and conducting regular surveys among the general public on AMR to inform strategies on health promotion.

The theme for the 2022 World Antibiotic Awareness Week (18-24 November) is “Contribute Together to Combat Antimicrobial Resistance!”. Antimicrobial resistance is everyone’s business. The Hong Kong Centre for Health Protection has a dedicated page (https://www.chp.gov.hk/en/features/47850.html) with the latest information on AMR for the general public and healthcare workers. With concerted effort from healthcare professionals and all other concerned parties, we can combat AMR together in the coming 5 years and beyond.

The author contributed to the editorial, approved the final version for publication, and takes responsibility for its accuracy and integrity.

The author has declared no conflict of interest.

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