"Three Lows and One Missing" - Is China on target to deploy 700,000 general practitioners? (short answer: no)

by MICHAEL WOODHEAD

Being a medical journalist in Australia, I've come across a few academics and leaders of medical groups who have marvelled at China's stated aim to deploy an additional half a million general practitioners by 2020. In a country where there are 25,000 general practitioners, the numbers are mind boggling and the ambitious target seems laudable. When I say that this may be an unrealistic goal given the current paltry state of primary/community care in China, I am viewed as a something of an overly-negative cynic or even vaguely racist.

It's therefore reassuring to see that my expectations are in line with those of the president of the China Medical Doctor Association, Dr Zhang Yanling. This month the CMDA chief was one of several big potatoes who showed up at the "2016 GP Training Forum and 13th Community Health and General Practice Annual Conference" held in Beijing on 23 April

The main speaker at the meeting was National Health and Family Planning Commission (NHFPC) Deputy Director Liu Qian, who said that creating a primary care system was one of the key aims of China's healthcare reforms. He said the creation of a primary care workforce was seen as an important step by top leaders such as Xi Jinping and Li Keqiang, who sent a message to the conference to make serious efforts to implement the policy.

Director Liu made the usual top bureaucrat exhortations to strengthen/promote/deepen reform of the medical education system to make this so. However, even he was realistic enough to admit that of the current 120,000 medical trainees only 13,000 (about 10%) were training as general practitioners and some of them may be hospital based rather than in community clinics).

He also acknowledged that China's entrenched doctor system was geared towards hospital-based specialists and that there was only weak support for general practitioners. There is no culture of primary care in China and this is reflected in the lack of training opportunities, low social status of community doctors "and the trust of the masses of trust is not high". Unsurprisingly, therefore, being a general practitioner is not a very attractive career option for any would-be doctor.

Director Liu then went on to make more of the usual remarks about strengthening the education system to train more general practitioners and making more efforts in this direction  etc etc

He was followed by Dr Zhang Yanling of the CMDA , who expanded on what the director said by coining the phrase the "Three Lows and One Missing". General practitioners suffer from "Low Pay, Low Motivation, Low Social Status and Missing Education" said Dr Zhang.

He said that in words, China's authorities had expressed strong support for the WHO-expounded principle of primary care and having general practitioners as gatekeepers to the hospital healthcare system. However in practice, general practice was weak, underdeveloped and had only patchy distribution across the country, he noted. While there are some general practitioners in bigger cities and in some regional hospitals, the biggest gap for primary care was in township and smaller county hospitals which were often both understaffed and underused. Dr Zhang used the Chinese saying "Swallows sitting in the doorway" to express the deserted state of China's township hospitals - because patients do not trust the doctors and take their illnesses straight to the bigger hospital "centres of expertise".

Dr Zhang said three things are needed to build a primary care system in China:

1. A commitment to build a large and sustainable primary care workforce based on teams of well trained general practitioners who are well remunerated and have a graded career pathway, similar to hospital doctors, rather than being in a dead end job.

2. A robust training system that ensures the primary care workforce is motivated and highly skilled - including the retraining and upskilling of allied health practitioners and physician assistants to make a primary acre team. Dr Zhang said the current projections were that China should have 1 GP for every 2000 citizens, which would require 700,000 primary care practitioners by 2020. However, based on current training capacity of 172,000 doctors and doctor assistants, there would still be a shortfall of 400-500,000 general practitioners by 2020.

3. Training pathways including residencies will need a partnership between government departments of health and education along with medical professional groups such as the CMDA. Working together they will need to establish a GP training group with well qualified educators that can set standards, plan training place numbers and oversee assessment and accreditation.

Dr Zhang concludes that a general practitioner primary care system is possible so long as there is good policy, clear commitment from government and cooperation from government departments, industry, the profession and good guidance from academics.

The two day conference also heard from a host of academics and experts in primary care from China, Hong Kong and and foreign countries such as Canada and Australia.

We wait in hope to see if the fine words of the conference delegates are actually matched with government funding and backed by policy that is actually implemented.

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

Bound feet, pirate hospitals and frequent flyer patients: just some of the medical news stories out of China this week

Bound feet not all bad for bones

Women who had their feet bound according to feudal Chinese tradition are more prone to osteoprosis but their enhanced balance skills mean they do not have excessive fractures, a study has found. A review of more than 250 elderly women who had bound feet by researchers at Kunming Medical University found that they had higher rates of osteoprosis than women of similar age.
However they did not seem to be in worse health or be more prone to fractures, the study found.
"This might be explained by compensation in physical activity to improve body balance, implying the importance of improving or maintaining body balance in overall prevention strategies against fragility fractures," the researchers said.

Trademarks use to fight pirate hospitals 

The renowned Beijing Tianlun fertility hospital has trademarked its name after finding that other hospitals around China were setting up 'Tianlun' fertility clinics and claiming to be affiliated to the famous clinic.

Frequent flyer patient

A Jiangxi endocrinologist has been called to provide emergency inflight medical help to the same woman twice in a month, according to CAAC News. The doctor treated the women on a flight to Thailand after she fainted. On the return flight he again answered a call for help and found he was helping the same woman with the same problem.

More family doctors for Henan

The Henan government claims to have re-trained almost 10,000 doctors to work as family doctors in community clinics and township-level hospitals. The government said the re-training program meant that Henan could not make family doctors available to 60% of people in rural areas and 100% of people in urban areas.

 Guangdong gets locals to sign up for GP cover

The Guangdong city of Huizhou says it has  got 30% of target patient populations to enrol with a family doctor. The city health authorities want to arrange GP cover for children under five, pregnant women, the elderly and people with chronic diseases. The authorities say they aim to have 50% of people enrolled by the end of the year.

Tianjin hospital gets Dr Weixin

A hospital in Tianjin has set up a smartphone service to allow patients to get advice, information  and book appointments via their phones. However, users said the electronic hospital system was clunky, did not allow access to many departments and they still had to queue to pay for appointments

Serious disease insurance cover to be nationwide.

China's minister for social security has said that his department will fully introduce nationwide social medical insurance for serious diseases within the year. However, critics have saod that hospitals will use the cover to claim rebates for unneccessary treatments while local governments will not have the finances to support the scheme. Meanwhile a group from Renmin University in Beijing have suggested that micro-credit schemes be used to give poor rural people access to funds to pay for their medical bills. The scheme would operate in the same way as micro-credit programs running in developing countries to provides funds for business startups.

Family planning staff become child development aides

The staff of local family planning departments may move into child development work and away from enforcing the single child policy, if a pilot program in Shaanxi is successful. The program sees family planing agency staff assisgned to follow up children up to the age of three to ensure they are meeting basic development goals in care and education, according to Caixin.


And this week's violence against healthcare workers:

Zhejiang: An armed man opened fire in a Zhejiang hospital and had to be disarmed by police after he injured one man and threatened patients and staff in the Haiyang country hospital.

Shanghai: A drunk man took a hostage at knifepoint at the emergency department of Shanghai No. 9 People’s hospital yesterday morning and injured a policeman who intervened.

Hebei: a  gang armed with machetes smashed up the emergency department of Baoding Hospital and severed the hand of a man who was being treated for minor injuries from an earlier attack. The man had been involved in an earlier altercation with the gang and they had come for payback, police said.

Liuzhou: a man got 10 days administrative detention and was fined 200 yuan for attacking a female doctor at a Liuzhou hospital. The man hit the female doctor because he was unhappy with the treatment his father was receiving for a bladder problem.

Beijing: A patient with a grudge over hand surgery assaulted a surgeon at the Jishuitan Hospital. The patient had previously had eight stitches in his  finger and was unhappy because it did not bend the way it did before the injury.

My weekly medical news blog for 7th February

There have been few takers for GP training places in Nanjing. The city's community health centres need to recruit 110 family doctors to fill their positions but have only had 49 applicants. Under new health ministry regulations, all doctors including GPs must have the 5+3 education and training (5 years undergraduate and 3 years postgraduate.) However, despite offering a masters degree and a one month placement with GPs in Taiwan, most medical graduates have given the GP training scheme the cold shoulder. The reason is the low status and poor pay of 'community doctors'. After eight years training, GPs can expect to earn only about 80,000 yuan (US$13,000) a year, which is much lower than hospital-based specialists earn. Also there is no chance of promotion or career progression and GPs are expected to move around many clinics in suburbs and villages. Health educators say the Chinese government needs to put more emphasis and resources into primary care if it is to develop a healthcare gatekeeper system similar to those used successfully in developed countries.

Most of the 'research' published by China's doctors is rubbish and there's a simple reason for this - the publish-for-promotion system. To gain promotion (and often just to stay in the job) all China's doctors have to meet a certain quota of  papers published in medical journals. The problem is that most of China's doctors are way too busy treating patients to be doing research and writing up papers. Many are simply not interested. The result is a thriving industry in academic fakery and plagiarism. It is common knowledge that doctors hire 'publishing agents' and ghostwriters to source the articles that will be published under their name. Ironically, many of the articles are written by medical students, and so there is an inverted system whereby the most knowledgeable and experienced clinicians are publishing articles written by the least knowledgeable. The going rate is about 3000-4000 yuan for a good paper - payment on publication, of course. Experts say the system has become a wasteful farce, and they are calling for reform of the one-size-fits-all quote system, to divide doctors into three categories: 'craftsmen' (no research, just treating patients), physicians (some research) and medical scientists (more  research, fewer patients).

The government says it expects to see a dramatic increase in uptake of private medical insurance before 2020, with new policies encouraging Chinese citizens to take out private cover. Ma Xiaowei, deputy head of the health ministry, the National Health and Family Planning Committee, told a news conference this week that the central and provincial government would "encourage the development of various types of commercial insurance to increase people's ability to deal with risks posed by major diseases." He said private cover was needed to help fund demand for health services, with the number of people over 60 already exceeding 200 million. However Mr Ma didn't explain how people will be enticed to take out private health insurance given that there are currently virtually no private doctors or hospitals and very few services or benefits from having insurance.

Underpaid, overworked and under fire: that's the life of an emergency medicine specialist in Guizhou province, according to a Sina article this week. In China, emergency doctors accompany ambulances and are often first on the scene of trouble, even before police. One doctor said he often had to jump in and stop bleeding in stabbing victims while people were still fighting around him. Another said emergcny doctors were often faced with physical challenges such as getting critically ill patients down stairs of apartment blocks with no lifts. Emergency doctors said they worked 24 hour shifts then had a day off during which they mostly slept, and there was no time for leisure, holidays or study. The stress of daily life as an emergency doctor meant there were high rates of burnout - and doctors were considered grizzled veterans if they lasted three years, they said.

In clinical news, new research shows that older Chinese are consuming more calories - and eating more unhealthy food - than their counterparts of the previous generation. A study from nine provinces found that the average daily energy intake had increased among older Chinese adults from 1379 total kilocalories in 1991 to 1463 kilocalories in 2009. The increases had come from greater consumption of high fat and high carbohydrate foods such as plant oil, wheat buns, and wheat noodles.

Chinese are also consuming more polluted air and it is killing them as much as smoking. A study carried out by the School of Public Health in Peking University found that there were
257,000 premature deaths related to PM2.5 pollution in 31 major Chinese cities. This made air pollution a major killer equivalent to smoking. Conditions such as lung cancer and stroke triggered by air pollution killed about 18,000 people in Beijing alone in 2013, the researchers said.

And finally, a study from Shanghai as shown that the number of cervical cancer diagnoses in the city has increased six fold in the last decade. Data from 13,518 women with gynaecological cancers  from 2003 to 2013 showed that the number of women with diagnosed gynaecological cancers increased by almost sixfold with the increase largely due to the increase of women with newly diagnosed cervical cancer. The study also showed that the age of diagnosis of cervical cancer had increased.

My January news blog ...

Regrettably, I am cutting back on my blogging about China medical news this year. I've been doing this for more than a year now, out of enthusiasm and my own personal interest in the area, but it's becoming too much of a burden on my time. And of course it is all unpaid. Unless there is a sponsor out there who wishes a regular stream of China medical news? After my day job doing much the same thing about Australian medical news I find it hard to sit down at home and do the writing for this blog. So from now on I shall probably only update the site about once a week. That is not enough to cover the many things happening in healthcare in China, but that's your lot. As they say in Yorkshire, you don't get owt for nowt.

This week I have been reading about how patients in Shanghai with chronic diseases will now be able to pick up their repeat prescriptions from community clinics instead of the big hospitals. It's a move intended to relieve the overcrowding at the tertiary hospitals and sounds like an obvious and sensible idea. Whether it will work or not depends on whether China's hospital-obsessed patients can be persuaded to show up at the low-status community clinics.

There are also moves to try curb China's high levels (approaching 50%) of caesarean section intervention in pregnancy. A feature article by Yang Wanli describes how some obstetricians in China are trying to persuade women to opt for natural birth. However, the barriers are a lack of available analgesia for women in labour and the industrial production-line mentality of China's hospitals.

Rural health is a major issue in China this month, with the State Council approving a plan to boost the rural medical workforce. The Council wants to see rural areas of China have qualified doctors replace the current 'barefoot' practitioners. However, well-meaning intentions will not fix the huge rural medical workforce problem in China. The simple problem is that university qualified doctors do not want to work in rural villages. The pay is pathetic, there is no status and the workload is high. As this article shows, the current rural medical workforce is mostly unqualified and often dangerously lacking in skills.

That's not to say that rural health is completely hopeless in China. There have been great achievements in some areas of public health such as immunisation and basic child health. However, as a major article by Chinese paediatricians the Archives of Diseases in Childhood shows, the next step for China is to try reduce the incidence of more complex diseases in children. China has done well in tackling the easily preventable causes of child disease, now it must turn its attention to the difficult stuff - the consequences of preterm birth, and the many congenital and metabolic diseases.

One problem with monitoring China's progress in child health is knowing whether or not the official  figures are true. Take measles vaccination for example. According to official reports, China has 95% measles vaccine coverage of infants. But when researchers analysed the causes of measles outbreaks in Hunan and Jiangsu that affected hundreds of children they found that the actual rates of measles immunisation more like 80%.

And finally, for those who put their faith in western healthcare companies helping improve the health of China, take a cautionary look at the sorry tale of GSK. A well regarded company in the west, GSK was the subject of high profile bribery allegations and a court case that jailed one of its British executives for  his role in the bribes to doctors and hospitals. Now the company is reported to be cutting the jobs of 1000 employees in China following the downturn in its business there (including a 60% drop in revenue).

"Family doctors" refuse to work in community

by Michael Woodhead
Guangdong province has trained more than 50,000 family doctors in the last few years but only 20,000 of them have opted to work as general practitioners in the community, a conference has been told.
Most of the doctors trained to be general practitioners have been put off by the low pay, low status and unattractive career prospects of community medicine and have opted instead to stay in the "more developed" hospital system, according to a speaker at the inaugural Guangdong Provincial Association of Family Physicians. Dr Wang Jiaji, head of the Family Physicians Association said patients should be able to enrol with a community-based family doctors and be offered treatment for minor illnesses and referrals for more serious conditions. However, he said the current environment for family medicine in the province made it unattractive to medical graduates. He said Guangdong had planned to have 2 GPs per 10,000 residents but currently only had one GP per 10,000 people, and this was far behind the level of 5 per 10,000 residents seen in developed countries such as the US. To try change the situation, he said Guangdong had become the first province to set u[ a local family doctor association, to encourage better training and make general practice a more attractive career. He also called on the government to invest more in primary care.

China's move to a GP-based primary care system: lots of policy, little progress

In China the average salary for a GP is about half that of a hairdresser.

by Michael Woodhead

If you relied on the official Chinese media you could be forgiven for thinking that China's primary care system was the best thing since sliced bread. Hardly a week goes by without an article extolling the virtues of the new networks of general practitioner-based community health clinics.

Many cities such as Beijing and Shanghai are strongly encouraging all residents to enrol with the local community medical centre and to visit the GP for everyday ailments rather than going direct to hospital. The public are enticed to see GP clinics with incentives, such as the free or low cost availability of GP clinic services and ease of getting to see a GP with little need for waiting or queuing up for registration, as is the case with hospitals. Unfortunately, the great Chinese public are not buying it, and they continue to make a beeline for hospitals whenever they are sick.

This week a revealing commentary in the Quarterly Journal of Medicine paints a more realistic picture of China's fledgling GP system. In fact, fledgling isn't the word, foundling might be a better descriptor.

According to the article by Dr Kong Xiangyi and Dr Yang Yi of the Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, the primary care system is in a kind of "Failure to Launch" status. They say the government's stated aim of training 150, 000 GPs by 2015 is pie in the sky. The problem, it seems, is that nobody wants to be a GP and nobody wants to see a GP. In China, to be a doctor in the community health service is a low-status position in an underfunded and unrecognised branch of medicine. As the two doctors point out, "the average annual income of a Chinese GP is less than half of a hairdresser and far lower than a specialist."

Part of the problem is that there isn't really any good local model for the would-be GP to emulate. There is no real definition of a GP, and currently many GPs are little more than barefoot doctors - local clinic practitioners who have received five years of basic training in health and medicine. They are employed to offer the "Six Basics" of health: prevention, health education, women and children’s care, elderly care, immunisations and physical rehabilitation. There is also a three-year postgraduate program for medical graduates to train as GPs, similar to that seen in western countries. However, there are very few takers for these courses and their impact on the national medical workforce has been minimal.

The authors of the article say that there appears to be little real enthusiasm for creating a genuine general practice system in China. As they put it, there is a lot of policy, but very little concrete support for funding and training programs. There are no primary care institutions or programs in China: the speciality is a career dead end, and the cream of China's medical expertise and social status is still centred around the big teaching hospitals.

The solution, according to the authors, is for China to emulate foreign countries that operate well-funded and high status family medicine programs. The aim must be to create a gatekeeper system in which patients are triaged by the GP before being allowed to see a specialist. And conversely, GPs must be enabled to provide follow up care after a patient is discharged from hospital. To do this, the health ministry needs to harness the skills and the prestige of the major hospitals to implement such programs.

Until that happens, patients will continue to avoid the community medical clinics, which are underfunded and have poor quality and outdated equipment. The lack of funding means that GPs have to charge commissions on drugs and medical supplies, further eroding trust in their services.

"China’s current reforms still do not emphasize enough the value of GP led primary care," they conclude.

Patients ignore primary care clinics | Decline in Hepatitis A | Online ratings platform launched for hospitals

The government's newly created network of primary care clinics are struggling for recognition in China, according to a new survey carried out in Chengdu. More than 60% of people surveyed had not heard of the primary care clinics and didn't know where they were located, according to local media. Most people surveyed also said they would still prefer to go direct to hospital for treatment rather than go to a local community clinic, the survey showed.

China has seen huge reductions in hepatitis A over the last two decades, with rates of infection falling from 94% to 42%, a study carried out in Hebei has shown. Rising living standards, better hygiene and widespread childhood immunisation have contributed to the drop in hepatitis rates, and also resulted in most infections being delayed until adolescence rather than infancy, according to researchers from Shijiazhuang. However, the lower infection rates mean that many people now have little immunity to the disease and will benefit from immunisation, the researchers say.

A Tripadvisor-like mobile online platform has been developed that allows patients to rate their experience with hospitals and health providers in China. The Care Voice (Kangyu in Chinese) is a Shanghai-based  social platform that enables consumers to share reviews on hospital services, physicians and treatments and connect with other patients and professionals.

Robot surgery for Chengdu | Aussies help with primary care | Weibo cancer medical fee man dies

Robotic surgery is now being used by hospitals in China, with the da Vinci surgery robot system completing its first operation at the Provincial People's Hospital in Chengdu. The 30 million yuan ($5 million) system can perform accurate and less invasive surgery in cases such as prostate cancer and gallbladder procedures but has been criticised by some clinicians as being an expensive system with a steep learning curve that does not offer any real improvements in outcomes compared to conventional surgery.

China is turning to Australia for advice and training in how to expand its primary health system. The National health and Family Planing Commission has asked Melbourne-based Professor Shane Thomas of Monash University to help guide the pilot programs of primary care taking place in Shenzhen. Monash is also hosting 24 Chinese health managers who are attending a leadership-training program at the School of Primary Health Care.

A Chinese man with cancer who became famous for using Weibo to solicit donations for his medical bills has died. Noodle shop owner Li Gang of Zhengzhou raised $16,000 to pay for medical treatment which he could not afford in 2012. His message went viral and he had many visitors to his noodle shop, but some commentators said it highlighted the lack of affordable medical care for most Chinese people with cancer.

Beijing introduces private health insurance for primary care

by Michael Woodhead
Beijing has introduced a pilot scheme of private health insurance to cover primary care services such as child health checks, maternal and perinatal care, postoperative rehabilitation and elderly care.
The service, which will be available through 23 community health centres allows those with insurance cover to tailor the type and level of services to suit their family needs.
The program is being offered online through the "Beijing General Practitioner and Family Care Reform Portal" website. The project has been set up jointly by the Beijing Medical Association and  China Life insurance
According to the BMA's Dr Wu Yonghao, Beijing residents will be able to purchase "Community Care Insurance" that will entitle them to various services provided by family doctors.
The service will also be offered as an add-on for patients who have insurance cover for procedures such as surgery, cardiac interventional procedures, orthopedic surgery and childbirth. General practitioners will provide the community care, including assessment, counselling, referrals and follow-up.
Insurance will also allow consumers to gain access to health checks, fast track referrals and personalised care.
The first of the "Family e-sites" is expected to go live in October and cover six districts of the city. By 2016 it is expected that 23 community health centres will cover all districts  of Beijing. Dr Wu said all community GPs will be qualified practitioners with at least five years experience as a specialist in the public system.
The program combines two of the National Health and Family Planning  Committee's health reform priorities: a move to private health provision and the development of primary care and community care services.

Shenzhen takes to family doctors

by Michael Woodhead
On International Family Doctor Day a Shenzhen joint venture clinic with Hong Kong University is claiming that general practitioners are proving popular with patients. 
The HK University Shenzhen Hospital clinic offers a GP service in which patients with chronic diseases can book face to face appointment with their family doctor. The clinic has an 80% return rate and the main diseases treated are cardiovascular disease, diabetes, arthritis and mental health problems, according to GP Dr Liu Ruihong. He said other hospital clinics are not open to external referrals, and only accept internal referrals. However, the GP clinic works on international model in that a GP can refer to the hospital clinic and vice versa. He says that according to WHO criteria, patients with chronic diseases are best treated by a generalist doctor with continuity of care and an emphasis on preventive care. With good GP care, patients with chronic diseases can stay healthy and avoid the need for hospital treatment for decades, he says.
After six months of a pilot program, the clinic is proving popular with patients and an increasing numbering are registering with the clinic and returning to see their personal doctor, he added.

Why are GP community clinics unpopular in China?

by Michael Woodhead
A recent article about medical services in Shanghai noted that hospital clinics were severely overworked, with patients facing hours in the waiting room to see a doctor for just a few minutes. In contrast, the nearby community clinic was very quiet, with doctors there underemployed. Now an article has been published claiming that community clinics are underused because they are inefficient and the doctors there lack the expertise of hospital medical staff. According to columnist Xin Ya, community clinics need competition from private clinics to lift their game. The writer says the old state service model on which community clinics are based means they provide only the most basic medical facilities and the service levels are poor - due to the unmotivated 'iron rice bowl' mentality of the staff.
Public community clinics in China are characterised as 'gatekeepers' but the writer says the offer little benefit to patients as they stock only the most basic drugs (due to their non-profit model) and they lack investment in equipment. The doctors are unmotivated because they are on a fixed salary and get paid the same regardless of results, with no performance targets or bonuses.
According to the columnist, a recent visit to the gatekeeper provide frustrating because they did not even have the basic equipment such as needles and sample test tubes to collect blood, and so a prson requiring tests had to go to the hospital to get a full examination.
The author say the government should remove the restrictions on private clinics setting up in competition to the current network of community clinics. In this way, 'the survival of the fittest' will occur as privately-invested clinics will have a motive to offer better services and better facilities to win patients. The government also needs to remove restrictions on doctor's employment contracts to allow hospital doctors to provide community clinic services and earn larger salaries there.
"In the future, private clinics should be as free as the restaurant competition ... and let the market decide who can survive," the article says.
"For community clinics, public sector and private medical institutions are like 'the lion and the antelope' - the establishment of a competitive community "gatekeepers" system, will improve the overall quality of medical care for residents, and allow them to enjoy affordable and quality services."

Undercover patients reveal poor standards of care in rural clinics

by Michael Woodhead
Rural health clinics provide poor medical care because the clinicians working in them have inadequate training, little equipment and poor working practices, a study based on sending 'undercover' patients has revealed.
Researchers at Shaanxi Normal University tested the quality of  care provided at village and township health clinics by measuring the responses to undercover patients who had been trained to mimic patients with angina or dysentery.
In an analysis of the content of  72 patient visits to 36 different clinics, the quality of the consulation was found to be very poor. The average length of each consultation was seven minutes, but only one and a half minutes was spent interacting with the patients - most of the time was spent writing prescriptions.
The village doctors made a correct diagnosis in only 26% of the consultations and were completely wrong in 41% of interactions. The most common incorrect diagnoses were ‘indigestion’ for the dysentery patients and ‘sprain’ for the angina patients.
Village clinicians asked less than 20% of the recommended questions for the health condition and  performed only 15% of the necessary examinations for the condition. Most of the questions were focused on prescribing a medicine. For the patients with chest pain, clinicians did not ask the crucial question about whether pain was radiating, and only 11% measured blood pressure.
Rural clinicians were poorly equipped to deal with conditions such as heart attack. For heart problems,  less than half said  they had the necessary equipment to treat moderate cases. Most had a stethoscope and blood pressure measuring equipment, but few clinics had an ECG monitor.
Medications were prescribed in 75% of consultations, but they were either unnecessary or harmful 64% of the time. The village clinicians often failed to refer serious cases, even when they got the diagnosis right.
The average cost to the patient was between 10 and 15 yuan, with most of this cost being for medicines prescribed.
Only 20% of the village clinicians had completed high school and most had only a rural physician certificate as a qualification. Most of their income was made from selling drugs or devices, with only only 351 yuan per their monthly income of 1355 yuan not coming from sales.
The researchers said it was clear that rural clinicians were not yet ready to act as the front line fighters in China’s primary care system.
"If recent reforms that expand access to rural health care are to lead to actual gains in population health, more attention should be paid to improving the quality of care delivered by the rural health system," they said.
"China has recently made enormous strides in providing access to health care for rural residents; however, efforts focused on improving the quality of care delivered by grassroots providers will be essential for reforms to lead to actual gains in health."
The findings are published in Health Policy and Planning.

"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.

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.

Beijing to extend family doctor enrolment scheme

So long as they have a health card and access to a computer, most Beijing residents will this year be able to enrol with a family doctor to get easier access to healthcare. The family doctor scheme that is currently operating in areas such as Fangzhuang and Desheng will be extended to cover most districts of Beijing in the next year according to the local department of health. At present the scheme covers 4 million households and almost 9 million people, according to the Legal Evening News (Fazhi Wanbao).
Under the scheme, residents must sign a contract with the 'health team' at their local community clinic and register with a specific doctor to receive regular appointments. This ensures continuity of care and guaranteed access to the doctor via an appointment system. The advantage of the scheme for patients is that they do not need to go to a large hospital and face long waits to register and bee seen in the outpatient clinics.
According to the health department, the scheme is now extensively used by residents in the initial areas, and the average income for doctors in the scheme is around 80,000RMB, about half the income of doctors working in the tertiary hospital.

Medical stories from the Chinese language press: why won't people use community clinics?

EastDay.com has a story about why Chinese people still prefer to take all their ailments direct to a high level hospital rather than seek treatment in a local community clinic. The main reason, it seems, is 'peace of mind' for pateints and their families in getting the right diagnosis. If patients go to a community clinic and are told their illness is only minor, they feel a nagging sense of unease that the local doctor may have got the diagnosis wrong or the small clinic may not have had the best equipment to do diagnostic tests and scans. On the other hand, if the clinic decides the illness is serious and refers the patient to the 'big hospital' the patient then feels they have wasted their time at the local clinic and could have saved time and money going direct to the higher level hospital.
 The article gives two case histories of patients who expressed frustration at their vague diagnosis and treatment at community clinics. One patient was told she might be having a heart attack, and only had this ruled out at the major hospital. Another patient believed her child had a congenital defect and was unable to have this checked properly at the local clinic and had to go to the Children's Hospital to have this ruled out.
The article says that around 70% of patients presenting at major hospitals have only minor illness and could be treated equally well at local clinics. However, for the time being there is little willingness among the public to rely on these clinics, it concludes.

Gansu starts generalist training program to provide more family doctors

by Michael Woodhead
Authorities in Gansu province are to implement a new generalist medical training program across the province to provide family doctors to all communities. In an announcement made by the province's health department based in Lanzhou, new measures will be implemented to create a training pathway that will equip doctors with skills in areas of medicine such as internal medicine, surgery, obstetrics, dermatology, psychiatry, eye diease and infectious diseases and rehabilitation medicine.
The department said medical practitioners currently undergo training in a 5+3 year model of academic and clinical followed by vocational training that provides a specialist pathway. The only generalist practitioners are those who work in rural areas with only three years of clinical training. The aim of the new program is to provide generalist practitioners who have advanced skills in many areas of medicine to provide a family medicine service, the government said

Beijing residents start to consult family doctors at community medical centres

Beijing resident, Dong Suxia, 63, has hypertension and coronary disease.
Instead of enduring long waits at various hospitals, Dong goes to a community health service center to visit a doctor she signed up with a year ago.
"The doctor is patient and gives me detailed advice on a healthy lifestyle. She even calls me to see if I take the medicine correctly. You don't see this in big hospitals," said Dong.
Dong is benefiting from a family doctor plan rolled out in the city in 2011.
According to the plan, community health service centers should set up teams consisting of a general practitioner, a nurse and a healthcare assistant, and sign contracts with patients suffering from chronic diseases in the neighborhood.
The goal is to channel chronic patients away from overburdened large hospitals and better monitor their condition.
Desheng community health service center in Xicheng district, which Dong visits, is one of the first grassroots healthcare providers to sign up patients and has taken a lead in chronic disease management.

Foreign doctors find over-treatment and lack of trust in Chinese medical practice

In front of a community health clinic nestled in a hutong in Dongcheng district stands a signboard that reads in Chinese: "British doctor, feet checked for free." Inside the clinic is Dr Gilbert Shia, 56, who examines the feet of people at risk of diabetes for early warning signs of the disease.
Born in Hong Kong, Shia studied medicine and practiced in the UK for around 30 years before he relocated to Beijing in 2006.
As a general practitioner (GP), Shia was lured to China to be a part of the government's reforms to the healthcare system. "I think the British [general practice] concept is suitable for China. If I want to promote it, I need to come to the place where policies are made," Shia said of why he chose Beijing over other cities, including his parents' hometown of Shanghai.