Theoretical contribution of the findings

This is the first study to explore how different aspects of organisational culture across public and private healthcare organisations influence GPs’ consultation styles in Hong Kong. The study has enhanced understanding of the literature by exploring the public-private comparison in organisational culture and its influence in an Eastern primary care setting. My findings offer new perspectives on the dimensions of national culture which impact the organisational style and patients’ approach to consultation style, and how they in turn influence GPs’ consultation styles (Tables 2 and 4). The next section elaborates on how national and organisational cultures influence GPs’ clinical practice in Hong Kong and compares the different results from other healthcare literature worldwide.

166 5.4.1 Influence of patients’ healthcare utilising behaviours on GPs’ information exchange with patients

Firstly, my work provides original insights about differences between older and younger generations and shows that national culture seems to have a stronger influence on older Chinese patients’ fearful and respectful attitude towards GPs, favouring a paternalistic consultation style. Findings from other higher power distance⁸ countries such as Romania, Belgium and Poland also showed a similar attitude by patients towards their GP but offered no further explanation on the impact of age differences (Meeuwesen et al., 2009; Verma et al., 2016). Similar to the paternalistic GP-patient interactions observed in the current study, Meeuwesen et al. (2009) and Verma et al.'s (2016) studies had what Hofstede described as a higher power distance in the GP-patient relationship, higher uncertainty avoidance towards medical care and higher assertiveness in the GPs’

consultation style. Some younger Chinese patients, in contrast, were found to be more proactive about their disease and treatment, shifting GPs’ consultation style towards SDM to satisfy their expectations of medical services in the current study. These findings for younger Chinese patients correspond with GP-patient interaction patterns reported across lower power distance countries such as the UK, Switzerland, the Netherlands, Germany and Sweden (Meeuwesen et al., 2009; Verma et al., 2016). The current study has shed a contemporary light on younger Chinese people, whom ‘doctor-shop’ GPs to seek reassurance over their uncertainties about medical services. This proactive yet mistrustful attitude towards GPs, possibly influenced by the way primary care is organised, is not as commonly seen across the UK, Switzerland, the Netherlands, Germany or Sweden (Lo et al., 1994). A classic example is that the NHS in the UK prevents doctor-shopping by allowing each patient to be formally registered with only

8 Higher/lower power distance indicates a higher/lower unequal distribution of power

167 one chosen GP (National Health Service England, 2019).

5.4.2 Influence of Confucian work values and management style on GPs’ prescription behaviour

The current study showed an interaction between the Confucian work values and authoritative management styles to produce low staff wellbeing in the public sector.

The current study, and that of Chiu (1999), found that Confucian work values, non-assertiveness, avoidance of conflict and submission to authority contributed to work stress and dissatisfaction among Chinese healthcare workers in Hong Kong and Singapore. Under difficult work situations, public GPs from the current study, and nurses in Chiu's (1999) study felt burnt out, dissatisfied from a sense of helplessness and fearful that they could not overcome the sense of blame from growing public expectations of medical services. To deal with clinical uncertainties, public GPs in Hong Kong were found to reclaim control from patients using a paternalistic style. Such feelings were not found among GPs from individualistic countries such as the US and Australia, who were more assertive and dominant in facing authority and conflicts (Chiu, 1999). Similarly, Farzianpour et al.'s (2016) study in Iran found that an authoritative GP-management relationships indirectly contributed to emotional exhaustion and depersonalization among healthcare workers. In contrast, most private GPs in the current study, given the interaction between more individualistic work values and a more engaging management style, were more willing to explore clinical uncertainties with patients using SDM, which concurs with findings across individualistic societies such as the UK, the US, Canada and the Scandinavian countries (Borg, 2014). Another important and original contribution is that this study expanded upon Chiu's (1999) study by demonstrating that in an Eastern context, private GPs differed from public GPs in

168 work values and their prescription behaviours.

5.4.3 Influence of patients’ emotional and verbal expressions on GPs’ information exchange style

The current study and that of Karasz et al. (2012) have shown that patients’ verbal and emotional expressions when discussing symptoms, preferences, options and medication requests impact on the patient-centeredness of GPs across Hong Kong, the UK, the US and the Netherlands. Some GPs in Hong Kong reported that proactive patients facilitated their SDM practices while resistant patients prompted them to use a more paternalistic or informed style, rushing to close the treatment discussion. The shifting consultation styles of GPs in Hong Kong resemble the way GPs from the UK, the US, the Netherlands and Belgium detected and responded to patient cues and the communication flow of the consultation (Karasz et al., 2012; VanRoy et al., 2013).

Initially, GPs from these studies offered a treatment plan according to the patients’

symptoms. They then observed patients’ verbal and facial reactions in response to the offer, and finally decided if a doctor- or patient-centred style would be more appropriate to carry on the discussion (Karasz et al., 2012; VanRoy et al., 2013). This study contributed to the knowledge that GPs in the Eastern context were also highly sensitive to patients’ words, non-verbal attitudes and gestures towards the use of SDM during treatment discussion.

5.4.4 Influence of uncertainty avoidance and service focus on GPs’ prescription behaviour

This study found interactions between uncertainty avoidance and service focus on GPs’

prescribing behaviour. In the current study, most private GPs in Hong Kong,

169 acknowledging the high level of uncertainty avoidance which led patients to doctor-shop in the competitive market, was found to please patients by prescribing what they wanted. A similar interaction pattern was found among GPs in Poland, Belgium, Greece and Italy in a societal environment of high uncertainty avoidance and pressure towards patient-centred prescription (Borg, 2014; Deschepper et al., 2008). Public GPs in Hong Kong were also found to want to please their patients with their limited range of prescriptions. However, unlike private GPs, they were trained and expected to provide patient-centred care in a non-competitive market. Therefore, public GPs recognised being able to relieve patients’ uncertainties through adhering to their prescriptions as an achievement. These findings were consistent across the current study and with previous studies with lower uncertainty avoidance cultures such as Canada and the US (McMullen, 2012; Tentler et al., 2008; VanRoy et al., 2013). The current study has furthered understanding of national culture by highlighting the role of high uncertainty avoidance and its impact on GPs’ service focus and their prescription styles across the public and private sector.

5.4.5 Mandatory learning culture facilitating patient-centred consultation styles Previous studies from the UK, Canada, the US, the Netherlands, Belgium and Italy found an association between GPs’ age and completion of communication training and their perceived readiness and willingness to practise patient-centred styles (Elwyn et al., 1999; McMullen, 2012; Schuling et al., 2012; VanRoy et al., 2013; Vegni et al., 2005).

Past studies in the Netherlands, Belgium, and the UK underlined that a lack of workplace training among GPs caused doubts when they were challenged by patients or when using complex decision tools during consultations (Elwyn et al., 1999; Lipman, 2004; Stevenson, 2003; VanRoy et al., 2013). This study has provided a powerful

170 explanation of the clear-cut differences in training culture between public and private GPs in Hong Kong, with barriers to SDM training and practices mainly from the private sector. Public GPs, enjoying a mandatory learning culture with formalised support, felt more confidence to practise patient-centre styles. In contrast, some private GPs in Hong Kong felt less confident about practising SDM as they tended not to receive training support for using a patient-centred style within a voluntary learning culture. To learn about patient-centred consultation, younger GPs who entered the private market directly after graduation had to disguise themselves as patients to visit and learn from their competitor GPs.

5.4.6 Macro and micro factors influencing consultation styles

Other than cultural factors, my findings have also provided additional evidence on healthcare financing barriers to practise SDM, which were not found in previous studies from the UK, Netherlands, Canada, the US, Belgium and Italy (Elwyn et al., 1999;

Lipman, 2004; Luymes et al., 2016; McMullen, 2012; Saba et al., 2006; Schuling et al., 2012; Stevenson, 2003; Talen et al., 2008; Tentler et al., 2008; VanRoy et al., 2013;

Vegni et al., 2005). Financially, private GPs’ role as business partners allowed them more freedom and decisional control over care processes and prescription policies than was the case for public GPs. Private GPs could choose to see a patient and prescribe the most desirable treatment for them. However, public GPs, who served as salaried employees, were not allowed to choose to see a patient and were restricted to prescribe the more expensive and newer third-line therapies⁹ with fewer side effects.

9 Third-line therapy includes more expensive drugs from recent treatments with fewer side effects, prescribed under careful instruction after the first- and second-line therapies, reviewed and approved by drug and utilization policies in the HA Drug Formulary, a committee that is accountable for drug policies, guidelines, management and utilization across public hospitals and clinics (Hong Kong Hospital Authority, 2015a).

171 5.5 Implications of the findings for clinical policy and practice

This section highlights the existing practices, and the reason behind a policy reconsideration in the areas of GPs’ formalised certification and GPs’ corporate engagement. The following policy and practice implications take notes of the findings in the current study and other successful implementations of SDM worldwide.

5.5.1 A formalised certifying system for primary care doctors

Due to the lack of a standardised certification system for primary care doctors, my findings reveal the need to establish accreditation criteria, such as a diploma in family medicine, for doctors who wish to practise in primary care in Hong Kong. Similar registration policies for GPs are in place across the UK, the US, and New Zealand to govern GPs role, entry requirements, and continued professional education (CPD) in primary care practice (Institute of Medicine, 2010; Merkur, Mossialos, Long, & McKee, 2008; Miller et al., 2015). CPD provides a means for revalidation and maintenance of high quality care across the UK, the US, New Zealand, Germany, Spain, Austria, France, China, India and Indonesia by continuously exposing GPs to the latest medical knowledge in educational practice (Institute of Medicine, 2010; Merkur et al., 2008;

Miller et al., 2015). Legare et al. (2011) suggested developing a checklist of accreditation standards on core SDM competencies to act as international certification criteria for SDM-CPD programmes. A formalised system to certify primary care doctors would incentivise private GPs to complete patient-centred skills training and assessment to practise SDM though family medicine programmes.

5.5.2 Improving workplace wellbeing and GPs’ engagement in care processes

The public GPs in this study felt challenged by burgeoning demand and workforce

172 shortages in public hospitals. In Hong Kong, the Hospital Authority reported an attrition rate of an average of 5% among doctors and nurses in 2011 with a shortfall of about 300 doctors and 600 nurses in 2017 in the public sector, which is worsening the public-private workforce imbalance (Legislative Council Panel on Health Services, 2011; The Government of the Hong Kong Special Administrative Region, 2017). Previous studies from the US have highlighted engaging GPs in policies and corporate decisions as a crucial factor in improving their satisfaction, quality of community and hospital care, and clinical as well as cost-efficiency (Crump, Arniella, & Calman, 2016; Jarousse, 2014). Similarly, my findings indicate that engaging GPs more in decisions could boost their self-esteem and loyalty. The NHS has successfully engaged GPs and managers in learning, communicating and co-planning as a team in a series of leadership and development programmes (White, 2012). A similar leadership programme in Hong Kong could provide a platform for GPs and managers to communicate and learn to work as a team to bring about changes in operational challenges such as drug procurement or coordination of community care.