Heathcare privatisation: China adopts the US model

by MICHAEL WOODHEAD

Prepare for the Mayo Clinic with Chinese Characteristics. This year China is taking the first steps towards creating the equivalent of US group medical practices such as Permanente and the Cleveland Clinic.

The so-called "Doctor Groups" (Yisheng Jituan, 医生集团) are springing up around the country -  mostly in major cities of the affluent Eastern provinces. They are being set up in response to the loosening of the government's rules on how and where doctors can operate - clinicians are no longer tied to the tertiary hospitals and are now being encouraged to be 'fluid' and 'open'. In response, at least fifteen doctor groups have been set up in 2015 and 2016, usually based around one location and with one specialty.

These are not socialist collectives nor are they not-for-profit groups. Instead they are privately financed businesses that are being set up with large investments from major industrial players such as pharmaceutical companies. These are groups that are seeking profits and market share as a return for their investment. Not sure how PRC's Marxist theorists will explain this away.

A typical example is the Yibai Pharmaceutical Anhui Oncology Group. This covers ten leading cancer specialists and their staff, as well as specialist treatment facilities in the Anhui and Shanghai area - services that include diagnostic imaging, radiotherapy, microsurgery and chemotherapy. The pharmaceutical backer has invested hundreds of millions of dollars already and is hoping to use its industry experience and connections to package other services such as pharmacy, supply chain and IT services. According to an investment analyst, the Yibai group is hoping to make 500 million RMB profits within two years.

Yibai is just one example: others include the Medical Imaging Group - an alliance of imaging facilities covering 27 hospitals including the Beijing Union Medical College Hospital, and Beijing PLA General Hospital.

Another doctor group is United Lige, which has a looser structure covering many cities and provinces including Beijing, Tianjin, Shanghai, Chongqing, Jiangsu and Zhejiang. It aims to bring smaller groups of doctors together in private clinics under the Lige banner.

Others Doctor Groups include

• Sanjia (Mobile phone referral, liaison etc services)
• Mingyi Hui (a multi-speciaity consortium that aims to offer family care from children to the elderly, with an online/telehealth emphasis)
• Song Dong Lei Neurosurgery Group (Shanghai)
• Pumai Doctors Group (collaboration with Chow Tai Fook to set up polyclinics in Shanghai)
• Yongchun Male PLastic Surgery Group ( Shanghai Woxin Hospital)
• Fenlan/Huaxia Pathology Group (Set up with more than 120 pathologists in conjunction with the China Medical Association Pathology Society, this group has received 30 million investment and will provide specialist pathology services via a network of 60 hospitals).
• Famous Doctor Fertility Group (Shenzhen based, set up by veteran Obstetrics and Gynaecology specialist Gong Xiaoming)

Most of the private doctor groups are financed by domestic companies, many with little healthcare experience. But rather than doing joint ventures with western healthcare companies to get foreign know-how, Chinese newcomers to private healthcare are simply buying up foreign healthcare providers. The Luye Medical Group recently bought the Australian private hospital consortium Healthe Care for $938 million. Luye's Charles Wang says the new doctor groups aiming to do business outside the big hospital environment lack operational expertise, and they are hoping to transfer such skills from the Australian outfit to the Chinese market.

This is what he told the Australian Financial Review:

"When things change in China, they tend to happen very fast. Doctors and practitioners forming their own doctor groups is something that never would have happened until last year. They are now leaving the public sector and forming their own groups, and once that gains momentum, you will see it rapidly become more westernised."

According to the AFR, the idea is not to parachute Australian executives into China, but to export the way Australians manage their hospitals, including finances, procurement, risk and clinical control.

"I expect you'll see, in time, structured medical programs, and we'll go up to China and do training and bring middle managers down here in Australia. In clinical areas there will be doctor mentoring and nursing programs,"  says Healthe Care's CEO Steve Atkins.

My own view is that it will take a lot to break up the power of the big hospitals. There are a lot of vested interests involved. The move to private doctor groups also raises the question of what impact this will have on the capacity of the existing public hospital system. If the most talented doctors can work outside the system, who will replace them? If top surgeons take two-three days a week doing private work, who will fill their positions in the public hospitals for clinical work and training?

There are many unknowns, but with official backing from the health minister and the Premier, expect to hear a lot more about Doctor Groups from 2016 onwards.

Three vastly different articles on medical disputes - which one gets closest to the truth?

by MICHAEL WOODHEAD
Violent and disruptive medical disputes have become so common in China that they barely rate a mention in the media any more. There has to be something quite different about an attack on doctors for it to make the headlines these days. The recent incident in which a mob of disgruntled relatives of a former patient took over a Shenzhen hospital and forced doctors to kowtow to a 'shrine' was one such incident.

In response, the Chinese authorities have said they will now adopt a new zero-tolerance approach to such protests and attacks on healthcare staff.

"Vice Public Security Minister Huang Ming said police will crack down on hospital-related crimes and show zero tolerance to perpetrators who assault and injure medical personnel. He made the remarks at a meeting on safeguarding order at hospitals and promoting harmonious doctor-patient relations on Thursday."

Ho hum - we've heard it all before. Every time there is a violent attack on hospital staff there are pledges to crack down, strike hard etc etc. A few weeks later it is business as usual. As I've written on this blog before, nothing will change until the government addresses underlying reasons for these disputes: under-resourcing of hospitals leading to ridiculously high throughput of patients - 3 minute consultations in which patients are barely listened to and prescribed the most expensive treatments (so that the hospital can get a bigger profit).

According to the latest empty promise to 'take action' the minister Huang "ordered better settlement of medical disputes by taking precautions, conducting risk assessment and spotting and containing disputes at an early stage." Gee thanks.

The article also makes the implausible claim that the number of hospital-related cases of violence continued has fallen four years in a row, and is down 12.7 percent year on year. The reality is quite the opposite.

And while on the subject of propaganda, the Hong Kong based SCMP, always keen to peddle a  more palatable version of Beijing's policies to foreigners, this week has an interview with a doctor who believes the answer to medical disputes is in looking to China's history. In a Q&A article, journalist Zhuang Ping throws a few easy questions to Dr Yang Zhen, a surgeon and deputy chief of the hospital administration office in Shanghai’s Zhongshan Hospital.

Dr Yang says China should take a look at how doctors in China traditionally established good relations with patients. Other than a few glib statements about being nice to patients and showing a more human face, he doesn't explain how doctors will make this happen when they have to rush through 80-120 patients in one short shift ( and prescribe enough drugs to them to hit their salary bonus target). All pretty worthy sounding but meaningless, really.

The article with the greatest insight into China's medical disputes in published in an academic journal (Health Economics, Policy and Law) and is based on interviews with 12 doctors from a multitude of specialties working in Shenzhen.

Interestingly, the article starts off by directly contradicting the claims of the public security minister,  quoting figures from the China Hospital Association showing that the number of medical disputes has increased by about 20% a year.

"Once worshiped as ‘angels in white,’ members of the medical profession in China are facing unprecedented challenges. Due to the deteriorated public trust during the marketisation reforms of the last three decades, Chinese physicians are working in an antagonistic environment. Heavy workload, low remuneration, and tainted social prestige have left millions of physicians feeling undervalued and
made medicine a career to be avoided, a situation rarely seen in other Confucian societies," it notes.

The article makes several points about medical disputes that have been raised before - but also includes one new one that is unique and potentially game changing.

The authors say that whatever the causes, medical disputes are rarely settled through legal channels, despite there being an officially recommended dispute resolution pathway and laws that in theory should cover medicolegal areas of dispute. The reality is that patients and their families have found that they are much more likely to get results - and get them much faster - if they take matters into their own hands. In other words, mob rule. According to the article, aggrieved patients and relatives of those affected by medical misadventure have found that they can get financial compensation and see their grievances gain attention if they take violent and disruptive action against hospitals and their staff. In practice this means staging demonstrations, blockading departments - and even whole hospitals - and threatening staff. They do it because it works.

This is the testimony of one of the doctors interviewed:

"Because the macro political environment attaches paramount importance to the so-called
‘maintenance of social stability,’ hospital managers are very afraid of high-profile incidents because local government may blame them for failing to mitigate the tension. If payment can quench patients’ anger, hospital managers would certainly love to do that, even when the patients are obviously blackmailing them. Patients also know the hospitals’ mentality very well, and actually take advantage of it. Some have chosen to stage farcical protests because doing so best maximized their interests. In fact, they deliberately avoided legal resolution because they knew hospitals would satisfy their monetary demands anyway."

The article goes on to say that hospitals fear high-profile protests because of the detrimental impact on their reputation, (which would inevitably affect their income) and also the political mandate imposed by local government to avoid mass incidents.

"They are also generally reluctant to resort to legal channels as litigation will not only ruin their reputation, but also consume a great deal of energy and time. Many studies have identified private settlement as the most popular means of resolution, even when patients’ complaints are clearly
unreasonable," it says.

In a second part of the study, two thirds of 300 doctors surveyed described relations with patients as 'very tense' and a similar proportion (65%) had been physically assaulted at least in the previous year.

The authors of the study say there are several key lessons for preventing and managing medical disputes in China. First and foremost is the need to reduced doctors' workload to a level where they have time to interact with patients and spend a meaningful amount of time with patients to allow good communication, adequate assessment and diagnosis and explanation of medical matters so that patients can make 'informed choices'.

Secondly, there is an urgent need to remove the profit/bonus incentives for doctors so that they paid according to their performance on good clinical practice rather than on how many drugs they have prescribed.

The study authors have a rather bleak outlook about the possibility of curbing attacks on healthcare staff - at least in the short-to-medium turn:

"For decades, health policy reform proposals have always put financing reforms, realignment of provider incentives, or organizational restructuring first. However, the [medical dispute] crisis in China shows policymakers and advisors the detrimental consequences of hostile interactions between doctors and patients. While it is not unreasonable to expect systemic reforms to restore trust between the two parties, one must bear in mind that it may take much longer than anticipated to see the effects; in the meantime, the dysfunctional doctor–patient relationship continues to deteriorate," they conclude.

Top 10 hospitals in China

by MICHAEL WOODHEAD

I'm not a big fan of top 10 lists, and I would approach this one for hospitals in China with caution. The China 2014 Good Hospital Ranking is produced by the Fudan University Institute of Hospital Management.

I'm not quite sure what criteria they use to decide what makes a good hospital but they claim it is based on factors such as clinical competence, scientific research and academic rigour. How they measure that objectively is anyone's guess. The Fudan team also say they consulted many 'national experts' to rank the country's top hospitals. They say the rankings are a good guide to clinical excellence and should be a benchmark that other hospitals strive for.

I don't think anyone is going to see any surprises in the list - all the top hospitals are the 'usual suspects' in the major cities such as Shanghai and Beijing and Guangzhou. I'm also not sure what the point of league tables for hospitals is - if you asked me to name the top 10 hospitals in Australia I could tell you quite easily without having to do a ton of homework - just based on location and whether they are teaching hospitals with a good research culture.

The rankings actually extend to 100 top hospitals, but I've only listed the top 10 here for brevity. I'm also not sure what the point of doing these survey on an annual basis is - it's not as if hospitals will move up and down the list very much and whether that is significant anyway. Any doctor will tell you that some good hospitals can have very bad departments and vice versa - some hospitals have a good reputation in certain specialities and can be terrible for others. Much of it is down to personalities and medical politics. I can also think of some 'good' hospitals that are over-rated and charge exhorbitant fees based on their reputation and "closed shop" monopoly status.

But what do I know. Here's the list:

1. Beijing Union Medical College Hospital
2. Sichuan University, West China Hospital
3. People's Liberation Army General Hospital (aka 301 Hospital, Beijing)
4. Shanghai Jiaotong University Affiliated Ruijin Hospital
5. Xijing Hospital (No 4 Military Hospital) Xian
6. Zhongshan Hospital, Fudan University, Shanghai
7. Huashan Hospital, Fudan University, Shanghai
8. Zhongshan Hospital, Guangzhou (First Affiliated Hospital of Sun Yat-sen Univeristy)
9. Tongji Medical College Hospital, Shanghai (Huazhong University of Science and Technology)
10. Peking University First Hospital

Doctors tempted by offers from private hospitals

by MICHAEL WOODHEAD
As China tries to develop its private healthcare sector, some doctors are contemplating a move from their high workload, low paid public hospital positions to the private sector. One Shanghai obstetrician with 10 years' experience was interviewed by Caijing and said he was tempted to make the move to the widening private sector, but not for financial reasons. He said he could already earn 300,000Y (US$47,000) a year in the public hospital, counting bonuses, which was comparable to the private hospital salary. What attracted him to private work was the lower workload and the opportunity to have more patient continuity.

"In public hospitals every day you need to see hundreds of patients, and you have no energy left to do academic work, research and innovative practice. In the private hospitals there is reduced patient throughput and often the patient will follow you from start to finish - and this is a more valuable medical experience," said Dr Liu. "None of my friends who have switched to a private hospital have shown any regrets," he added.

Another reason for moving into the private sector is independence, say doctors. One said that private hospitals offered more clinical and financial autonomy than a public hospital where you worked under the authority of a 'big medical leader' and were also subject to the rigid career path and control of hospital management. In a private hospital there was more opportunity to select your patients, treatments and also have an equity stake in the business, he said.

However the doctor noted that there was less job security and often questionable quality of care and backup in private hospitals compared to the public system. He noted a clear divide between domestic and foreign-funded private hospitals. Foreign joint ventures tended to have little interaction with public hospitals as the quality of care was generally good. However he saw many 'referrals' of patients from private hospitals where patients had not been properly assessed or had spent tens of thousands of yuan for minor ailments. Most of the doctors in the tertiary public hospitals would opt for foreign-invested hospitals, he suggested.

Inequality in China healthcare - fixing it isn't easy

by MICHAEL WOODHEAD
The Chinese government acknowledges that serious inequalities exist in the country's healthcare provision - rural areas are seriously under-serviced compared to the cities. 

More than a decade ago the government announced a grand plan to try address some of these inequalities - by sharing the expertise of big city hospitals with rural areas. The plan was for medical personnel from tertiary hospitals in prosperous eastern China to spend time in placements and long-term exchanges in disadvantaged rural hospitals and clinics in poorer parts of western China.

However, the so-called "Myriad Doctors Supporting Rural Health Care Project" has not been a complete success (to put it mildly), according to a letter in the Lancet this month from Dr Wang Tao of the Shanghai Jiaotong University Sixth Affiliated Hospital.

After touring western districts to see the progress of the project in its 10th year, Dr Wang found that it had helped bring medical personnel and technology to some poorer areas. However, the project was also under-resourced for such a major undertaking. Lack of funding meant that hospitals struggled to pay their seconded medical workers an adequate wage. The transfer of five senior doctors from each supporting [eastern China] hospital to a disadvantaged hospital on six-month shifts also proved impractical.

"These long-term arrangements create a huge burden for hospitals in eastern provinces and can cause personal difficulties for medical staff," he writes.

Another problem was that medical resources were allocated by government bureaucrats rather than determined by need.

"Coordinating this huge project that involves thousands of hospitals and medical workers according to strict policy guidelines is extremely tough, and inefficiencies and repetitive allocation of resources inevitably arise," says Dr Wang.

The project has not done much to address inequalities in healthcare, he reports. Latest figures show that eastern China areas have average annual healthcare funding levels of 1067 yuan per person, whereas in western China hospitals have only half that level of resources (about 500 yuan per person). Inequalities also exist in the numbers of hospitals, doctors, nurses and beds between eastern and western China.

"Healthcare inequalities remain a serious problem and necessitate support projects for the foreseeable future," Dr Wang suggests.

He asks whether market forces could succeed by encouraging hospitals in eastern provinces to open public or private amenities in the western provinces.

"New sources of income might provide sufficient motivation to create efficient, high-quality services. The fear is that new sources of income might cause new problems, counteracting the government's attempts to reduce inequality. Nevertheless, the consistent provision of an excellent level of health care in China, particularly in less developed areas, still has a long way to go."

Medical school places unfilled: nobody in China wants to be a doctor, and there are three good reasons why they don't

In western countries there is fierce competition to get a place in medical school. Only straight A students with an impressive portfolio of extra-curricular activities need apply. In China, the picture is very different. Even the top medical schools in China are struggling to attract students.

This week, Professor Yang Jun a distinguished cardiologist and head of the First College of Clinical Medical Sciences, Hubei, notes that Shanghai's prestigious Fudan University has had to drop its entrance mark threshold by 58 marks this year. The same "dumbing down" has been seen at the city's Jiatong University medical school and other medical schools across the country. When China's top medical school at  Peking Union Medical College allotted 10 places to Guangzhou students, only four applications were received - and of these only one was deemed to make the grade.

What's happening? The fact is, nobody with any ambition wants to be a doctor in China right now, and you can see why. The three main reasons are poor pay, long hours and terrible working conditions - including the real possibility of abuse and violence.

Writing in the International Journal of Cardiology, Professor Yang notes that the average salary of a doctor in China is 72,000 yuan a year (US$11,600) -  and many doctors earn a lot less than that, especially if they work in unpopular specialities such as paediatrics or emergency medicine (the so-called ambulance riders).

Poor pay for doctors in China: paediatricians are at the bottom, with only 63,000 yuan a year

For this salary, doctors have to work long hours - more than 50% of doctors work more than the 'specified' 40 hours a week and 30% work more than 60 hours a week.  Doctors also face huge workloads - as many as 80 patients in a single morning shift. As Professor Yang observes, the Mayo Clinic in the US has fifteen times more staff than the Peking Union Medical College, and yet it has only half the patient numbers.

Doctors in China simply don't have time to practice adequate medicine - and the consequences are unhappy patients who take out their frustration on staff. A recent survey of almost 10,000 doctors found that 60% had recently experienced abuse from patients, and 13% had experienced physical assaults.

Doctors also have to study long and hard to qualify - up to ten years including undergraduate and postgraduate qualifications. On top of this they have to publish articles and to gain academic merit for promotion.  Doctors have lost the status and respect they once had - and only 6.8% of doctors say they would advise their children to follow  a career in medicine.

This is already causing problems in the less popular branches of the profession. On 27 July, the National Health and Family Planning Commission announced that it would be waiving the usual entry criteria for admission to the specialities of paediatrics and emergency medicine. Medical student candidates who did not achieve the usual pass mark would be allowed to become trainee paediatricians and emergency medicine doctors if their coursework was of sufficiently high standard, the NHFPC announced. This has caused outrage among  doctors currently working in these specialities, who say it is a desperate and self -defeating move that will further reduce the attractiveness of their branches of medicine.

They say there is a need to improve pay and conditions in their work rather than lowering the bar to entry. Paediatrics and emergency medicine and notoriously poorly remunerated and yet high pressure jobs in the Chinese healthcare system. Assaults on doctors in these departments are numerous as they are in the front line seeing critically ill patients - especially the treasured offspring in a one-child system.

The doctor's social network site DXY echoed many of the criticisms of the "dumbing down" move. As one doctor wrote: "We work longer hours for less pay in unsafe conditions, but we stick to our posts because of the duty we have to the little ones who thank us after we have care for them."

The medical side-effects of China's stockmarket crash

by MICHAEL WOODHEAD

Headaches, irritability, depression and most of all insomnia are the most common medical side effects of China's stockmarket crash, doctors say.

Mental health specialists at Guangzhou's prestigious Sun Yat Sen Hospital say they have seen a stream of unwell patients this week suffering from the mental effects of severe stress from the stockmarket collapse.

"Some people can not sleep at night, have difficulty falling asleep or wake up in the early hours three or four times a night.
Many people have overt physical symptoms such as palpitations, chest tightness, aches and pains, stupor and confusion," says psychiatrist Dr Wei Qinling.

Dr Wei says the worst affected people are those with a casino mentality towards the stockmarket and those with little mental resilience, who are most at risk of severe depression, mental confusion and possible suicide risk. Other common reactions are despair, alcohol abuse and loss of motivation. Some workers in the finance industry say there is nothing to work for anymore, and they have lost a reason to work. Others have lost their livelihoods altogether. Dr Wei says some have gone on extreme drunken binges to try wipe out the stress.

And in what some are calling "stocks syndrome", people suffers from sever stress from the sudden reversal from riches to destitution. This is a mix of severe anxiety, guilt, frustration and mental paralysis. Dr Wei says some people have symptoms that are so severe they may require hospital admission and antidepressant treatment.

However, at the Beijing Union Medical College Hospital Department of Psychological Medicine, Dr Li Jianzhong says some people are looking for a quick fix for symptoms such as insomnia. Some of the most difficult to treat are those who were most greedy when the market was good and became obsessed with the stockmarket. After making large gains they are now in denial and are unable to accept that they have made losses and cannot adjust to reality. Counselling may be needed, but it requires people to learn about "spiritual wealth" as well as financial wealth, he says.

Dr Li says there are two steps to treating "stock syndrome". Firstly, people must identify the cause of their symptoms and learn to manage the stressors through activities such as deep breathing and findings distractive activities such as walking or sport. Secondly, people must find an alternative to obsession with the stockmarket and focus on that.

In Shanghai, psychologist Dr Chen Gong says there has been an increase in patients with 'financial stress' but it would be an exaggeration to say his department has been overwhelmed. For him, two of the most serious consequences of mental stress from the stockmarket are cardiovascular and cerebrovascular disease. These may be triggered by severe stress, and people must learn to change their habits and behaviour to have a more balanced life, he suggests. Another problem with financial stress is its effect on the family,and relationships, he adds. He recommends that people talk openly with their family and focus more on family activities rather than being preoccupied with speculating on shares.

Dr Wei, however, warns that for some people the stockmarket has become a form of addiction, just like gambling. He warns family members to look out for signs of addiction and to recommend counselling and treatment for those who have become addicted to the stocks - and are at risk of withdrawal symptoms.

Starlet snubbed; swears at surgeon

by MICHAEL WOODHEAD
The Chinese public's dissatisfaction with the offhand and uncaring medical treatment they receive in state-owned hospital extends even to celebs. The China tabloids are today running the sensational gossip story of how singer and  Journey to the West star Han Xue (韩雪) lost her temper and screamed at a doctor who she was seeing at a Shanghai hospital for conjunctivitis.

The star has since apologised after her outburst hit the headlines, writing a piece on her Weibo blog about how the doctor treated her in a rude and offhand manner and refused to listen to her questions.

According to Han, she went to see a doctor at the Songjiang Branch Shanghai First People's Hospital after she developed a red eye from working underwater in a swimming pool as part of a film shoot. She got a ticket and waited in line like everyone else, only to be dismissed after just a cursory examination when she finally got a few minutes with a doctor.

Han Xue said the female doctor's attitude was indifferent and impatient, as she refused to even listen to her explanation of the eye problem. After a brief look at her eye the doctor wrote a prescription without saying anything to her.

When Han Xue remonstrated with the doctor, saying that she wanted a proper examination of what the problem was, the doctor merely replied that she didn't need to ask questions and could assess everything by sight. The doctor said she was busy and didn't not have time to waste. After being given a prescription and dismissed, Han Xue asked what the diagnosis was. The doctor simply said it was not a bacterial infection. When Han Xue complained about the lack of information and how the way she was treated was insensitive, the doctor said she was not a psychiatrist and didn't have time for niceties with a 'trivial' complaint like conjunctivitis. Han Xue retorted that her eye problem was not trivial to her, and that the doctor had a poor and unprofessional attitude.

The doctor said she didn't care, and this prompted Han Xue to 'lose it' and let out a stream of foul abuse at her. During the rant, the starlet asked the doctor whether she had been bullied as a child, and whether she had lost money on the Shanghai stockmarket crash. Shen finished with a shout that the doctor certainly did not deserve the title "Angel in a White Coat" (often applied in Chinese media to selfless medical staff).

On her blog, Han Xue apologised to the public for losing her temper and using bad language, but said she still stood by her judgement of the doctor as "uncaring and irresponsible" .

In the same week, Shanghai media have reported three separate physical attacks on hospital staff by irate patients and their families.

China's government take the biggest step towards private healthcare

by MICHAEL WOODHEAD

This month China's State Council has announced its biggest ever policy move towards developing a private healthcare system in China: it has made private hospitals eligible for reimbursement under the national health insurance coverage plans. In other words, private hospitals can now compete for China's equivalent of 'Medicare' rebates. Since most urban Chinese are covered by some kind of national health insurance policy, this is huge.

The State Council announced a raft of other measures that will make it easier for private hospitals to compete against the giant and powerful public hospitals. The government has announced tax breaks for private hospitals and abolished a lot of regulatory barriers such as rules on bed numbers. It has also said that nonprofit private medical institutions should get subsidies from the government.

These changes are a signal of a major change in China's government health reforms. Up till now, the government has made incremental changes to try foster the development of private hospitals (or "private capital invested medical institutions" as the cosmetic-Marxist state media still refer to them).

The government has tried to encourage doctors to work outside the public system by abolishing many of the restrictions on 'moonlighting'. It has eased the rules on foreign companies investing in private hospitals. It has abolished the pharmaceutical profit-skimming by public hospitals by stipulating a no-commission policy on drug sales.

However, none of this has been enough. The small reforms haven't worked because the powerful State-Owned Enterprise hospitals have been the elephant in the room of China's healthcare system. They control the income (from health insurance and out of pocket payments), they control the real estate, the equipment ($2 million for an MRI machine anyone?) and the workforce - and they also control the medical training. It's also not too obvious to state that the big public hospitals are run by the local government - who make the rules.

The central government has finally woken up to the fact that the only way to truly reform the healthcare system is to undermine it. The new deregulation steps will divert revenue from the public hospitals and give investors the belief that there is a genuine business case for private hospitals to succeed in a tough market.

Until now, the private hospital sector has been small, stymied and suspect. Official figures say that private hospitals account for about 10% of hospital beds - and patients, with most private hospitals being small specialist clinics of limited influence. The small private hospitals have never had the capital or networking to compete in purchasing power with the big government funded hospitals - and hence have a reputation for having limited equipment, staffing and resources. Many of the privately operated clinics have a reputation for offering aggressively marketed but suspect services (fertility and impotence clinics, cosmetic surgery etc) and for overcharging.

In the Chinese media, analysts are saying the new deregulation changes will awaken investor interest in the private hospital sector - with specific interest coming from pharmaceutical companies. One example is Shanghai's Fosun Pharmaceuticals, which has a subsidiary "Hospital Medical Investment Management" company that has just signed a "framework agreement" to set up private hospital services in Yulin City

It remains to be seen whether the changes will help the National Health and Family Planning Commission (NHFPC) and Chinese government achieve its aim of doubling the number of private hospital beds from 10% of total to 20% by 2020.

The right and wrong way to do primary care: Shanghai vs Shenzhen

by MICHAEL WOODHEAD
Pilot programs in primary care have been carried out in two of China's largest and wealthiest cities since 2009: they used different models and it looks like Shanghai got it right and Shenzhen got it wrong. 

The basic difference between the two models of care was that Shanghai went with a more UK/European model of having independent general practitioner-owned centres that were publicly funded via a capitation model and which were based around multidisciplinary teams. Shenzhen, by contrast, used a more conservative approach based on clinics run by existing hospitals that installed GPs in rented premises and who were given only minimal funding, and thus they had to charge patients or make revenue from commission on drug sales.

In other words, the Shenzhen system was really just using primary care practitioners in the same failed model that currently operates in China's hospitals. GPs in Shenzhen felt underfunded and they had no support staff - and this inferior quality was noticed by patients. In an evaluation of 3421 citizens carried out by health researchers from Hong Kong, it was found that the perception of primary care quality among local residents improved in Shanghai since 2009, whereas it deteriorated in Shenzhen.

What were the factors that worked for Shanghai? According to the researchers, the Shanghai model was based on public-funded primary healthcare teams that included doctors, nurses and public health specialists. They tailored their care to local needs - offering programs for chronic diseases of the elderly such as diabetes and hypertension, and also for maternal and child health.

The Shanghai funding model was partially based on capitation - in other words, the clinics received about $20 a year per patient they enrolled. Enrolment with a community health centre was a key feature of the Shanghai model, with residents offered free care if they stuck with the same clinic rather than attend tertiary hospitals for care. The Shanghai GP centres were funded by local government and could provide services and prescriptions at no cost to local people.

In contrast, the Shenzhen clinics were set up and operated by hospitals, which ran them along the same lines as other hospital departments - namely with GPs having to derive their income from fees and drug sales. This meant that many patients had to pay upfront fees - especially as about 70% of the local populace are internal migrants and their fees are not reimbursable by their hometown-based health insurance policies.

It seems that Shenzhen's primary care clinics were Cinderella services - playing second fiddle to well-funded and high prestige hospital clinics. GPs were underpaid and poorly resourced compared to their hospital counterparts. No wonder patients perceived a lack of quality in their services.

The study authors make the obvious conclusion that the Shanghai model if the better one: "The quality of primary care improved in Shanghai but not in Shenzhen. This may be because, in Shanghai, beneficial long-term relationships between patients and general practitioners were supported by capitation payments and the provision of services tailored to local health priorities."

Source: WHO Bulletin

Statin therapy has disappointing results in Chinese patients

by Michael Woodhead
Only about one in four Chinese patients taking a statin have their cholesterol levels under control, according to a new study.

A review of the effects of statin therapy in 8965 outpatients with cardiovascular disease from 200 clinical departments of 122 hospitals across China found that about 75% of patients still had poorly controlled lipid levels.

The findings, published in the International Journal of Cardiology showed that despite taking long term statin therapy in medium to high doses, about 75% of patients had an above-target LDL-cholesterol level. In a similar manner elevated levels of total cholesterol and triglycerides as well as low HDL-cholesterol persisted in 34–43% of patients despite statin therapy, according to Professor Wei Yidong and colleagues at the Department of Cardiology, Shanghai Tenth People’s Hospital and Tongji University School of Medicine.

Only about 10% of patients overall had optimal levels of all lipid measures (LDL, HDL and triglycerides) despite taking statins. Patients with diabetes had slightly better control of lipid levels (43%) compared to those without diabetes (39%).

The study authors said it was not clear why patients taking statins did not have good control of their lipid levels. Oddly, there appeared to be no relationship between the potency of the statin doses and the degree of lipid level control.

About 77% of patients taking low doses of statins had LDL-C not at goal, compared to 72% of patients taking medium potency regimens and 74% of patients taking high potency courses of statins.
Chinese patients may need more intensive lipid-lowering therapy with additional agents other than statins, to improve their lipid levels. Patients may also need more attention on lifestyle factors such as diet and exercise before starting statin therapy, they added.

However, they could not rule out poor adherence to treatment a a possible cause of the poor lipid control.

Eight medical stories from China you should read

by Michael Woodhead

1. Beijing will start to enforce new anti-smoking laws with 200 yuan on-the-spot fines (up from 10 yuan) for people who smoke in public indoor shared areas, and institutional fines of 30,000 yuan (up from 5000 yuan). Cameras will be used to compensate for the lack of enforcement officers, especially after hours, the city government says.

2. The Chinese government has been accused of withholding medical care from dissidents. An article by Sophie Richardson in the WSJ says civil rights campaigner Cao Shunli is now in intensive care because she was denied access to medical care while detained for her efforts to promote a civil society.

3. A link has been found between damp housing in Shanghai and rates of asthma in children. Researchers from the University of Shanghai for Science and Technology say asthma symptoms could be reduced by 25% by simply keeping a child's window open at night.

4. A vaccine against enterovirus 71 developed by Sinovac Biotech has proved effective against EV71-associated hand, foot, and mouth disease or herpangina in infants and young children, according to a study in 5000 children done by the Jiangsu Provincial Center for Disease Control and Prevention, published in the New England Journal of Medicine.

5. Eating shark fin is not only cruel and bad for the environment, it is also a health hazard because of high mercury levels in the product, researchers from Zhejiang have shown. After testing samples of shark fin they found that up to 33% contained toxic levels of mercury.

6. Antibiotics are widely overused by parents in rural China, with more than 60% dosing their children with antibiotics bought over the counter, Shanghai researchers have found. Most parents were ignorant about how antibiotics worked and had little idea hat they do not help viral infections.

7. Migrant workers have little access to healthcare and many of them put off seeing a doctor for illness, a survey in Shanghai has found. Two thirds of migrant workers said they had never had a medical check up and nearly 40% said they had ignored symptoms because they couldn't get to see a doctor.

8. Health workers in Guangdong have completed a successful pilot trial of a cervical cancer screening program using the ThinPrep cytological system. The program offered Pap test cancer screening to more than 40,000 women, and found that improvements are needed in basic education regarding cervical cancer screening for young and poorly educated women.

"Fake" GPs in Shanghai | 5-in-1 vaccine shortage | Appointments by WeChat: China medical news for Friday 14 February

Shanghai appears to lead China in the introduction of family doctors, but many of the so-called general practitioners (GPs) are fake, says Zhu Shanzhu, the chairman of the Society of General Practice, Chinese Medical Association. In an article in Global Times, Dr Zhu says that Shanghai is on target to have a GP for every resident by 2020, when people will be able to register with a family doctor working out of their local community health centre. However, Dr Zhu says many of the family doctors assigned to the health centres are not true GPs because they are specialists such as surgeons. Shanghai must therefore commit to training doctors in family medicine, she said.

A second death has been reported from the novel influenza strain H10N8 in Jiangxi. According to Shanghai Daily, a 75-year-old man died in Nanchang. Health authorities have urged the public to stay away from live poultry.

Shortages of the popular paediatric 5-in-1 combination vaccine have been reported due to transport congestion and delays ove the Chinese New Year. The imported vaccine, made by Sanofi, immunises against diphtheria, tetanus, pertussis, polio and Haemophilus influenza Type B and costs around 600 yuan for each of the four doses. Parents prefer it over free domestic vaccines because it reduces the number of needles their child has from 12 to four.

Hospitals in Beijing are offering appointments and medical results via WeChat, ECNS reports. The social media service is being offered by 21 municipal hospitals to patients who sign up and obtain a password.

A Shaanxi woman claims one of her kidneys was secretly removed during an operation she had more than 20 years ago. The woman made the shock discovery that she was missing a kidney when she had a hospital scan for back pain. The only possible explanation was that it must have been removed when she had an operation on her ovaries 26 years previously, she told TV reporters. The woman returned to the hospital where she had the operation but they rejected her claims and denied all responsibility for the incident.

A hospital in Hainan is pioneering a new model of "treat first, pay later" care. The hospital in Haikou has dropped the usual registration system in which patients pay a deposit ahead of treatment. the hospital managers say the new system is more convenient, but relies of the trust of patients to pay for their treatment afterwards. Non-payers will be put on a black list and refused further treatment, they said.

A Beijing academic has called on the government to stop the tobacco industry's deceptive marketing of "low tar, less harmful" cigarettes. Professor Yang Gonghuan of the Department of Epidemiology and Statistics, Institute of Basic Medical Science, Chinese Academy of Medical Science, says the claim that low tar cigarettes are less harmful is incorrect. However the slogan is used by industry to encourage smokers to stay with the habit. Writing in Tobacco Control, he urges the government to "stop the execution of this deceptive strategy for tobacco marketing".

And a kidney specialist in Guangzhou has been praised in the Chinese media for continuing to work despite being confined to a wheelchair. Reports say Dr Ke continued seeing 20 patients a day at the PLA 458 Hospital over the Chinese New Year despite having broken her patella and being unable to walk. Patients praised the doctor but she said any of her colleagues would have done the same thing.

Shanghai hospitals' database hacked and records sold to drug companies

translated by Michael Woodhead
A 'mole' hacked into the databases of three major Shanghai hospitals using wireless laptops and extracted drug usage data that was sold to pharmaceutical company representatives, Eastday reports.
The Huangpu court has found two people guilty of fraud after they downloaded drug data from the three hospitals and sold it for 12,000 RMB to drug company contacts. One of the hackers worked in the technical department of one hospital, the other was a pharmacist. The hacker used a laptop computer while sat in a car in the carpark of the hospitals to hack into the wireless network. They were caught in July 2013 when IT staff noticed unauthorised users extracting data, and traced them to the nearby car park, where they were arrested by police. They were fined 5000 RMB and sentenced to one year in jail.
In the past, pharma companies would sometimes pay hospitals for the drug usage data, but this practice has been outlawed. The hackers made contact with drug company representatives and told them they could sell the information each month for 46 different drugs for 250 RMB per item. They emailed the data to the drug company employee, who will be tried separately for corruption.

Antibody vaccine for H7N9 is more effective than Tamiflu, say Shanghai researchers

translated by Michael Woodhead
Shanghai researchers say traditional inactivated vaccines cannot be developed against H7N9 but they have developed a gene vaccine which is more efficacious than Tamiflu against the virus.
According to an article in the Workers Daily, an antibody therapeutic vaccine that is effective against the current strain of H7N9 has been developed by Shanghai researchers and is now about to start  clinical trials. Researchers at the Shanghai Public Health Clinical Centre Infectious Disease Research Institute said they had developed antibodies that were effective against H7N9 in vitro and they are now starting tests in humans.
Professor Xu Jianqing of the Infectious Disease Research Institute said that work on the vaccine began in April last year after the first major H7N9 influenza virus outbreaks.  He said the team had made a breakthrough with a gene vaccine in December when they injected the vaccine into 30 mice infected with H7N9. After 30 days none of the mice had died and none had signs of H7N9 infection, which represented the first real proof of efficacy.
Professor Xu said many other research groups in China were doing H7N9 vaccine research but using  traditional inactivated vaccines. However, he said experiments had shown time and again that compared to other influenza viruses, the H7 influenza virus was not amenable to being incorporated into an inactivated vaccine, as it was deformed by the chemicals used, rendering the immune response inadequate. Similar efforts by Dutch researchers to develop a vaccine against the H7N3 virus strain in 2003 were also a failure for a the same reason. This showed that inactivated vaccine technology was not going to catch on for the H7 virus, he said.
The Shanghai researchers had therefore taken the bold step of taking the most important genetic material from the H7N9 virus and implanting it into a mature vaccine carrier. This was the equivalent of putting it into a safe and inserting this into a cell, said Professor Xu. And because the virus structure was not destroyed by putting it into an egg albumen, it elicited a good immune response, he added.
Professor Xu said the new vaccine would be suitable for people at high risk of H7N9 such as those working in live poultry markets and household members.
Within Shanghai's R&D community the new H7N9 vaccine was seen as a breakthrough after an audacious attack. Xu Jianqing said the immune system of H7N9-infected people produced antibodies, and the sooner the body produced antibodies the better the prognosis. He added that Tamiflu was effective if given within the first few days of viral infection, as this was the 'empty' window before the body had started producing its own antibody.  But after more prolonged infection Tamiflu quickly became ineffective,  and drug resistance appeared quickly. Researchers were inspired to try using exogenous antibodies during this initial 'empty window' period when there was no natural H7N9 antibody being produced. The observed effects of the gene vaccine were clearly better than Tamiflu during this period, said Xu Jianqing. In fact, in 2003 during the SARS outbreak, there had also been small scale treatment models of experimental antibody treatment that were successful in curing a patient.
It is reported that at present the H7N9 antibody treatment has already successfully completed two phases of in-vitro testing and it is estimated that Phase 3 testing will be complete within one month. From among the 100+ types of antibody currently in testing the best will be selected for clinical use.

China medical news headlines for Wednesday 29th January

Tuberculosis rates fall by 80%
Rates of tuberculosis in Shandong have fallen by 80% in the last decade, a study of 55,000 adults has shown.The prevalence rate of bacteriologically confirmed TB ases was 34 per 100,000 for adults in 2010. However, diagnosis of TB is now more difficult as half of bacteriologically confirmed cases did not present persistent cough, researchers said in BMC Infectious Diseases.

Man arrested for spreading H7N9 rumours
China's internet is full of stories of doctors and medical staff who have died of H7N9 influenza. Social networks such as Sina Weibo, QQ and WeChat have stories circulated by netizens of deaths of medical staff in Shanghai, Tianjing, Shenzhen and Nantong, according to CRI. However, health authorities have branded the stories as rumours and have arrested one man for spreading false information. In one case, a doctor who was named as having died of H7N9 influenza has startled patients by being on duty at hospital.

Shanghai life expectancy is 82
Life expectancy in Shangahi is 82 and a half years old, the Shanghai Health and Family Planning Commission has said. Women have a life expectancy four and a half years longer than, a report in ECMS said. LIfe expectancy in the city is on a par with developed countries but infant mortality including migrant families, rose from 5.04 per 1,000 in 2013 to 5.73 per 1,000.

High alert as H7N9 cases increase
China has gone on to high alert for H7N9 influenza as the number of cases continues to increase. Bird markets have been shut down in Shanghai and quarantine authorities have stepped up monitoring at airports. However, health authorities have played down the risk of a pandemic, saying the infection is not spread by human-to-human transmission. A vaccine against the H7N9 virus is being developed but is not ready for use in humans yet, authorities have reported.

China's can't cope with dementia
People in China are ill prepared to cope with the huge number of elderly people with dementia and Alzheimers disease, according to an article in SCMP. China has almost six million patients with Alzheimer's, 50% higher than a decade ago and twice as many as earlier estimated by the international health community. However, caring for dementia sufferers in China is left to family members with limited or no training and no support from the state.

Red Cross resuscitation ads are wrong
An advertising campaign by the Red Cross that urges Chinese to help those who have collapsed and need resuscitation is technically inaccurate, according to emergency specialists The picture on the ad shows a woman pressing the soft tissue of the patient's neck, which will lead to obstruction of the airway. First-aid practitioners should place their index finger and middle finger on the patient's chin bone, a doctor has pointed out.

Medical headlines: Violence against doctors in Xian | Family doctors unpopular | New Year depression

Violent attack at Xian hospital injures five staff
Five doctors and nurses have been injured and a Xian hospital severely damaged in an attack by irate relatives of a patient who died, Xinhua reports.
More than 20 people with iron bars burst into the fourth floor of the Xi'an Municipal Central Hospital to assault medical staff and causing damage including smashed windows and breaking furniture and fittings.
The violent incident was probably the result of a dispute between the hospital and relatives of a patient with meningitis who died in the hospital earlier. The doctor treating the patient is reported to be severely injured, and other medical staff members suffered bruises. Police are investigating the incident.

Family doctor system proves unpopular in Shanghai
The pilot family doctor system in Shanghai offers patients more contact with doctors for everyday illness, but many are reluctant to use the service, the Global Times reports. In a long article the Times says the new system is popular with older people with chronic diseases but is being bypassed by younger people with acute illness who want immediate access to a hospital and all its expertise. Doctors working as family practitioners also say they are losing heir skills by being away form the hospital environment.

New year blues
Many Chinese people are suffering from a malaise of lethargy and depression around the Chinese New Year period, the Global Times reports. Psychiatrists say it is quite common for Chinese to experience "year-end syndrome" when they feel tired, anxious and socially withdrawn. The condition is partly psychosomatic and may be worsened by the stress of returning home and the dark days of winter, doctors say.

H7N9 flu death doctor hailed as hero for continuing to work while sick

translated by Michael Woodhead
The Shanghai doctor who died of H7N9 avian influenza is being hailed in the Chinese media as a hero for continuing to go into work despite being sick.
The 32-year old Zhang Xiaodong who worked as a surgeon in the emergency department of the Pudong New Area Renmin Hospital, died on the 18 of January from pneumonia complications of H7N9 infection.
In an article published today, his colleagues said he was a hardworking doctor who worked in a very busy and understaffed department and did not want to let his colleagues down. They said it was extremely exhausting working in the surgical department and it was not unknown for a surgeon to perform five appendix removal operations in one shift.
On the 16th of January Dr Zhang came into work feeling feverish and insisted on staying at work despite feeling sick. The next day he felt worse and had an 'IV infusion' before resuming his work on his shift. However, his condition quickly deteriorated and he became critically ill and was taken to intensive care. He was put on a ventilator when he developed chest pain and breathing problems. A CT scan showed that infection had invaded many lobes of his lung. The top experts of the hospital were called in to oversee treatment and Dr Zhang received the best drugs available, according to a local newspaper, The Morning Times. However, despite the efforts to save him, Dr Zhang died without making a recovery.
His colleagues said Dr Zhang would not have wanted to miss a shift because the lack of staff meant one of the other doctors would have had to have done a 24 hour shift to cover for him.
Dr Zhang left a wife who was seven months pregnant. The hospital has filed a report of industrial injury and his family will receive compensation.

Shanghai doctor dies of H7N9 avian influenza: human-to-human transmission?

by Michael Woodhead
The H7N9 influenza-related death of an emergency department doctor in Shanghai seems to contradict the Chinese government's claims that the infection is only being transmitted from animals to humans and poses little risk of a major outbreak or pandemic.
The Chinese website ECNS reports that a 31-year-old doctor at  the Pudong New Area People's Hospital was one of three deaths from H7N9, two of which were in Shanghai and one in Guangzhou.
The doctor is said to have died of pneumonia and respiratory failure on Saturday after being infected with H7N9 avian flu virus.
The other case were a 77-year-old male farmer, Shanghai's seventh H7N9 bird flu case so far.
The deaths follow a claim by China's National Health and Family Planning Commission  on Friday that a large-scale H7N9 epidemic is unlikely because there is no human-to-human transmission.
"The virus is still spreading from birds to human, and the chances of large-scale human H7N9 infection are slim," the NHFPC statement said.
"Current cases are scattered, and no mutation of the virus has been identified so far that could affect public health," it said.
There have been 199 cases of H7N9 influenza and at least 45 deaths in China so far, and there are now about 4-5 new cases reported per day in China. The number of cases is also expected to increase as over Chinese New Year as it is the peak winter season for flu and people travel en masse and live poultry is bought and sold for family celebrations.
Update: The first probable  human-to-human case of H7N9 in China was reported in the BMJ in July by Qi Xian and colleagues at the Department of Acute Infectious Disease Control and Prevention, Jiangsu Province Center for Disease Control and Prevention, Nanjing.

China medical news headlines for Friday 17 January

Monitor and treat the best way for hepatitis B

Monitoring inactive chronic hepatitis B carriers is a cost-effective strategy for China, a study shows. The findings published in Hepatology, also show that increasing treatment, monitoring and adherence to therapy are necessary to achieve significant health benefits at the population level.
Shanghai researchers compared the current strategy of not monitoring inactive chronic HBV patients to a monitor and treat strategy which included twice-yearly assessment of HBV and ALT levels. For active HBV cases the researchers suggest treatment with the antiviral entecavir, which evidence shows to be a cost-effective antiviral therapy in China.
The study found that there were 1.5 million adult HBV arriers of HBV in Shanghai, of whom 63% were hepatitis B virus e antigen (HBeAg) positive. The number of active cases of chronic HBV, were 258,139 in the eAg-positive group and 152,384 in the HBeAg-negative group. A monitor and treat strategy would reduce liver cancer by 70% and reduce mortality caused by chronic HBV by 83%, according to News Medical.

China too hard for US generic drug maker

One of the world's biggest generic drug manufacturers has quit China, saying it is too hard to do business there. The US generic maker Actavis has said it will exit China because the business climate is just 'too risky' according to its CEO.
“It is not a business friendly environment,” CEO Paul Isaro is quoted as saying by Bloomberg.

Beijing wants foreign medical city

Beijing is to set up an International Medical Service Zone in Tongzhou District in 2014, Xinhua reports. The 15 square kilometre zone is intended to be a model of medical reform that will integrate social and foreign investment. Beijing hopes the zone will attract doctors and medical experts from Beijing's top public hospitals as well as draw in international medical institutions to set up shop in a healthcare hub. The aim is to have world-class medical facilities, education institutions, medical research personnel, rehabilitation and nursing homes and health management facilities all in one place.

TCM a leading cause of liver failure

Traditional Chinese Medicine is a major cause of acute liver failure in China, according to a report in PLOS One. In a review of 177 Chinese patients with liver failure, 17% had received herbal remedies, and TCM was believed to be a more frequent cause than any other factor, the Global Times reports. Of all the patients diagnosed with acute liver failure 44% developed the condition due to drug or herbal remedy toxicity, and herbal remedies, accounted for more liver failure than paracetamol.