醫局港鐵自我更新 還待政府積極督促

<轉載自2019年3月21日 明報 社評>

近年醫管局與港鐵表現屢惹詬病，行政長官林鄭月娥表示，世上沒有機構可以歷久不衰，公共機構需要自我更新，政府願意多些介入幫助。本港公共醫療和鐵路服務金漆招牌褪色，與醫管局和港鐵內部管治出問題有着密切關係，改革刻不容緩，大型機構往往存在結構惰性，傾向保持現狀、抵制變革，過去數年事態反映，港鐵和醫管局自我更新能力成疑，同類錯誤和問題一再發生，政府有必要發揮領導作用，大力介入督促革新，而非僅僅扮演從旁協助的被動角色。

醫管局港鐵敗象浮現 中年危機須對症下藥

醫管局和港鐵，表面上一間是公營機構，一間是上司公市，然而根據法律定義，兩者均是公共機構（Public body），需要向全港市民負責。醫管局管轄全港43間公立醫院以及上百間診所，負責照顧全港九成病人；港鐵掌控全港交通命脈，每日載客近500萬人次，雖無公營機構之名，卻有公營機構之實，絕不能簡單視為一般商業機構。

港鐵前身的地鐵公司於1970年代中成立，醫管局亦快到三十而立之年。回首當初，兩者表現確曾叫人眼前一亮。當年地鐵公司採用「鐵路加地產」模式解決資金缺口，取得空前成功，市民普遍滿意鐵路服務；1990年代初醫管局成立，統一管理公立和補助醫院，增加醫療經費改善設施，引領本港公共醫療服務水平顯著提升，可是現今市民醫護提起港鐵和醫管局，更多是搖頭嘆息甚至怒氣難平。

公共醫療和運輸服務需要不斷革新與時並進，醫管局和港鐵一直強調服務高效優良，可是近年市民看到的，卻是敗象不斷浮現：公院病人滿瀉，醫護不勝負荷，狠批醫管局管理失當；港鐵事故頻生，沙中線醜聞不斷，管理層監管不力，市民大失信心。醫管局和港鐵屢出亂子，原因不在於前線不夠努力，而是內部管治出了問題；醫管局和港鐵不約而同出現了「中年危機」。

昨天行政長官林鄭月娥在立法會接受質詢，談到醫管局和港鐵的管治問題。林鄭表示，世上沒有歷久不衰的機構，面對工作量增加，以及社會要求提高透明度，每個機構都有可能出現問題，最重要是經常反省更新。她希望公共機構能夠自我更新，倘若需要政府多些介入，當局願意協助。政府是港鐵大股東，手握逾七成股權；醫管局則是法定機構，需要執行公共醫療政策，政府督促醫管局和港鐵改善內部管治，乃是應有之義，現在的問題，不是應否從旁協助推一把，而是必須積極介入。

結構惰性窒礙改革 政府必須主動介入

「結構惰性」（Structural Inertia）是大型機構常見弊病。每當機構發展到一定階段，組織結構逐步正規化、制度化，負面效應也會隨之產生，容易變得僵化和抗拒變化，甚至認為「存在就是合理」，忘記初衷。結構惰性的產生，導致機構對外在環境變化反應遲鈍，應變決策權力操諸中高層管理者之手，可是他們與前線往往溝通不足，下情未能上達，管理者不了解前線問題，對環境變化亦不夠敏感，很容易形成認知上的惰性，以為一切都在掌握之中，直至危機爆發始知大禍臨頭。

種種迹象顯示，醫管局和港鐵都有嚴重的結構惰性問題。不少資深醫生批評，醫管局官僚僵化情况嚴重，行政架構愈益臃腫，以往一個會議可以決定的事情，現在隨時要開三四次會議。港大醫學院院長梁卓偉慨嘆，鞏固管治問責，與過分官僚僅是一線之差，就連去年重返公院工作的中大前校長沈祖堯，亦形容文書工作太多，有時令他「好忟」。近年公院人手流失率屢創新高，本是嚴重警號，可是醫管局管理層遲遲未有對症下藥，終令前線醫護怨氣全面爆發。

港鐵在沙中線工程醜聞的表現，同樣反映董事局和管理層對前線問題茫無所知，出事後亂作一團。若說醫管局問題在於架構臃腫處事官僚，港鐵的管治問題則在於定位取向。港鐵管理層將商業效益置於民生需要之上，關心小股東多於服務市民，公司業務愈益龐雜，車務本業和鐵路工程都未有做好，董事局雖有多名政府官員，卻未有發揮積極監督和領導作用，導致問題愈益惡化。

冰封三尺非一日之寒，由高鐵嚴重超支到沙中線醜聞，港鐵高層監管不力的毛病，可謂如出一轍，近年推出的改革措施，並未帶來真正轉變；數年前醫管局檢討督導委員會發表報告，提出多項改革建議，然而醫管局管治問題依舊每况愈下。大型科層組織的結構惰性，往往隨着歲月增加，若沒有巨大外來壓力，不易激發自我完善內生動力。過去數年港鐵和醫管局的情况，令人懷疑這兩間機構的自我更新能力，政府必須主動發揮領導角色，責成醫管局和港鐵高層從制度和管治文化入手，改變思維糾正弊端。

Organisational renewal is required in the Hospital Authority and the MTR

IN recent years, the performance of the Hospital Authority and the MTR has been repeatedly criticised. Chief Executive Carrie Lam Cheng Yuet-ngor has said that in this world there is no organisation that is everlasting and never declines. Public bodies have to undergo self-renewal and, if necessary, the government is willing to help. The tarnished reputation of Hong Kong's public healthcare and railway services is closely related to the internal governance of the Hospital Authority and the MTR. Reforms can no longer be delayed. Big organisations often suffer from structural inertia and have a tendency to maintain the status quo and resist change and reform. From what has been happening in the last few years, one doubts whether the MTR and the Hospital Authority are capable of renewing themselves. Instead of playing only a passive role of helping from the sidelines, the government must assume leadership and intervene vigorously to press these organisations for reforms.

Structural inertia is a common problem facing big organisations. When an organisation develops to a stage in which its structure becomes formalised and institutionalised, negative outcomes arise and the organisation becomes rigid and resistant to change. Because of structural inertia, the organisation becomes slow in responding to change in the external environment. The power of handling emergencies and decision-making is vested in mid-and top-level managers whose communication with frontline staff is often inadequate. Since the managers are unable to understand the problems on the frontline and are not sensitive enough to changes in circumstances, cognitive inertia is common.

Many senior medical practitioners have criticised the Hospital Authority for its bureaucratic red tape and bloated structure. Matters that could have been decided in one meeting in the past often have to go through three or four meetings now before a decision is made. The exodus from public hospitals in recent years has reached one new high after another. This is actually a serious warning signal but the Hospital Authority management has failed to tackle the problem by introducing appropriate measures. As a result, it has triggered a full-blown outburst of resentment among frontline medical practitioners.

If the problem with the Hospital Authority lies in its bloated structure and bureaucratic style, the problem with the governance of the MTR lies in its positioning and orientation. The MTR management puts commercial efficiency above the needs of people in everyday life. It is more concerned about its small stockholders than serving the public. While its businesses have become increasingly complicated, it has failed to do a good job in its principal business of transportation and railway construction. Although there are a number of government officials on the board of the MTR, they have failed to play an active role in supervising and leading the company. The problems of the MTR have therefore further deteriorated.

From the serious cost overruns of the Guangzhou-Shenzhen-Hong Kong Express Rail Link to the scandals of the Shatin-Central Rail Link, the MTR management's slack supervision has shown to be a persistent shortcoming of the company. Reforms have been introduced in recent years but have not brought about any genuine change. The Steering Committee on Review of Hospital Authority published a report a few years ago and many reforms were proposed. However, the problem of governance of the Hospital Authority continues to deteriorate. The structural inertia of a big hierarchical organisation often worsens with time. It is not easy for an organisation to find the motivation for improvement unless it comes under immense external pressure. From the situation of the MTR and the Hospital Authority in the last few years, one doubts whether they are capable of self-renewal. The government must take the initiative in assuming the leading role to demand the Hospital Authority and the MTR change their ways of thinking and rectify their problems by changing their structures and culture of governance.

醫局港鐵自我更新 還待政府積極督促

近年醫管局與港鐵表現屢惹詬病，行政長官林鄭月娥表示，世上沒有機構可以歷久不衰，公共機構需要自我更新，政府願意多些介入幫助。本港公共醫療和鐵路服務金漆招牌褪色，與醫管局和港鐵內部管治出問題有着密切關係，改革刻不容緩，大型機構往往存在結構惰性，傾向保持現狀、抵制變革，過去數年事態反映，港鐵和醫管局自我更新能力成疑，政府有必要發揮領導作用，大力介入督促革新，而非僅僅扮演從旁協助的被動角色。

「結構惰性」（Structural Inertia）是大型機構常見弊病。每當機構發展到一定階段，組織結構逐步正規化、制度化，負面效應也會隨之產生，容易變得僵化和抗拒變化。結構惰性的產生，導致機構對外在環境變化反應遲鈍，應變決策權力操諸中高層管理者之手，可是他們與前線往往溝通不足，管理者不了解前線問題，對環境變化亦不夠敏感，很容易形成認知上的惰性。

不少資深醫生批評，醫管局官僚僵化情况嚴重，行政架構愈益臃腫，以往一個會議可以決定的事情，現在隨時要開三四次會議。近年公院人手流失率屢創新高，本是嚴重警號，可是醫管局管理層遲遲未有對症下藥，終令前線醫護怨氣全面爆發。

若說醫管局問題在於架構臃腫處事官僚，港鐵的管治問題則在於定位取向。港鐵管理層將商業效益置於民生需要之上，關心小股東多於服務市民，公司業務愈益龐雜，車務本業和鐵路工程都未有做好，董事局雖有多名政府官員，卻未有發揮積極監督和領導作用，導致問題愈益惡化。

由高鐵嚴重超支到沙中線醜聞，港鐵高層監管不力的毛病，可謂如出一轍，近年推出的改革措施，並未帶來真正轉變；數年前醫管局檢討督導委員會發表報告，提出多項改革建議，然而醫管局管治問題依舊每况愈下。大型科層組織的結構惰性，往往隨着歲月增加，若沒有巨大外來壓力，不易激發自我完善內生動力。過去數年港鐵和醫管局的情况，令人懷疑這兩間機構的自我更新能力，政府必須主動發揮領導角色，責成醫管局和港鐵高層從制度和管治文化入手，改變思維糾正弊端。