China's primary care sector suffers from "Just a GP" syndrome

by Michael Woodhead

While the Chinese government aims to promote primary care and reduce the hospital-centred approach to healthcare, the situation at the coalface suggests this is going to be an uphill struggle. A report from Henan shows that while the city of Zhengzhou has 54 primary care centres, they are unpopular with both patients and doctors. According to an article in the local newspaper, the main problem is 'lack of talent'. The community medical centres fail to attract talented doctors because they are seen as a career dead end with low pay, low status and few if any opportunities for training or promotion.

A former respiratory physician who now works at one of the clinics says the failure to attract and retain reputable doctors to work a primary care centres is a vicious circle. With salaries of only 2-3000 yuan (US$300-400) a month for doctors working in community medical centres, the hospital based staff would rather switch to a remote rural branch of the hospital rather than work in one of the city-based community clinics, says Dr Song Gang, who became a primary care practitioner in 2008.

But it's not just the low wages that deter would-be general practitioners. Dr Song says doctors fear that in community practices they will only see minor problems and will therefore become de-skilled. This in turn will mean that they no longer qualify for promotion and career advancement, he says.
Another problem with the lack of 'medical talent' in community centres is that the few doctors who do work there are overworked, facing long hours for little reward. This again leads to a high rate of burnout and high staff turnover, as well as lack of continuity of care for patients.

Professor  Cui Liuxin, a specialist in public health at Zhengzhou University says the key to building up primary care is investing in talent, and making community centres more attractive to high level doctors. However, he says this is not going to happen overnight. In the meantime, local clinics and village hospitals are shunned by patients and represent a waste of resources and workforce. At the same time, city hospitals are overused by people with minor ailments, leaving them swamped and unable to cope with the high demand.

The Zhengzhou city planning commission says it aims to create a stronger primary care workforce as part of a six year plan  based on training and recruitment for community clinics. However critics say that a six year time schedule is unrealistic, and it will take even longer than this to build up a well-qualified and capable primary care medical workforce.

The workforce planning committee said that pilot programs had shown that doctors could be attracted to work in primary care community clinics with financial bonuses, investment in medical hardware and also with extra support support for ongoing doctor training and education.

It remains to be seen whether local clinics will be able to attract and retain high quality healthcare staff.

China's pediatrician shortage to worsen with two child policy

by MICHAEL WOODHEAD

In Guilin's main children's hospital this New Year there were only three doctors on call to cover more than 30 beds for children - and a long waiting list - around the clock. Last year there were seven doctors but four have resigned.

Doctors at the hospital say there is a vicious circle - as more paediatricians resign, the pressure on the remaining doctors gets worse, and the speciality becomes even less attractive to other medical graduates. Speaking to local media, paediatricians say there problem is an increasing one for the whole of China. Paediatrics is an unpopular branch of medicine that finds few takers.

One of the reasons is the low income compared to other branches of medicine - paediatricians don't get the opportunity to make extra bonuses or commissions from surgical operations, prescribing drugs or providing medical devices.

Secondly there is the intolerable pressure from pushy parents of Little Emperors. Children with only minor illness are brought in by neurotic parents who demand attention and excessive or inappropriate treatment for their child. Doctors working with children say their parents and grandparents can be obnoxious - expecting immediate treatment and instant miracles for their spoiled child. This often leads to abuse, disputes, complaints and legal action between doctors and families.

Thirdly, paediatricians also struggle with what they call the "dumb patient" problem - unlike adults, children cannot explain their problem well, and therefore doctors need much greater clinical skills to be able to diagnose their illness.

The low income, high pressure and lack of respect means that paediatricians get little satisfaction from their work. Not surprisingly, many vote with their feet and leave.

The lack of child specialists means that the remaining doctors face 12 hour shifts every day - and have to work as many as 10 night shifts a month. Paediatricians are already exhausted and demoralised  - and they expect the situation to become even worse as two child regulations come into effect in 2016.

Freelance "Doctor Groups" - the first sign of workforce reforms in China

by MICHAEL WOODHEAD

The creation of some 30 independent "physician groups" (Yisheng Shoutuan, 医生集团) is the first sign of the Chinese government's 2015 relaxation of working regulations for the hospital system. The rules have been relaxed to allow "workforce fluidity" - in other words to allow doctors to work where they wish rather than being bound to a single hospital ( a legacy of the old danwei work unit system).
 he Chinese Nationa Health and Family Planning Commission (NHFPC) wishes to create a more flexible workforce and to allow doctors to work in a more more market-oriented system, supposedly to free up medical talent and overcome the current mismatch in supply and demand for medical services.

It is still early days for these doctor groups, which face problems such as how to engage with hospitals, how ensure high quality medical standards and how to take on medicolegal risk (and insurance). These are things that are usually the responsibility of hospitals and something that doctors have not had to worry about in the past.

To try tackle these issue the Beijing Henghe Hospital has set up a "doctor group collaboration model platform" to try work with doctors towards new ways of working. The group has already started to look towards the US for business and working models for doctors. Initial discussions have revealed that 55% of hospitals have doctors doing some form of 'moonlighting' - and therefore the doctor groups may formalise this working model.

Another survey found that many talented young doctors were leaving the hospital system because of the long hours, high pressure and low pay. A new freelance model may help retain the skills of these doctors, the collaboration discussion group said.

However, other doctors have pointed to the fact that the vast majority of doctors continue to work  in the public hospital system, and they say this system (and its workforce) is already stretched to breaking point. They ask how the public system will cope if many of its 'backbone' doctors reduce their commitment to practising in the hospitals - and also the reduced input in areas such as teaching and mentoring.

The group heard from some leading doctors saying there now had to be a pragmatic approach to developing Doctor-Hospital Partnerships to ensure optimum allocation of medical resources and also recognise the true value of doctors.

In one Doctor Group forum, vascular surgeon Dr Zhang Qiang said there were 10 issues facing doctor groups:
1. Doctor groups are a very vaguely defined concept.
2. Policies have to be open, pragmatic and work with the health ministry and hospitals.
3. What size should doctor groups be? How much will they be worth? And what disciplines will the consist of?
4. How will doctor groups be organised? As private companies? Co-operatives/ Joint ventures?
5. Where will doctor groups be located? In private hospitals? In large institutions or be in stand-alone clinics? Or as flexible visiting doctors?
6. If doctors join freelance groups [how] will they maintain their participation in academia, teaching and research?
7. How will doctor hierarchy and work assignments/responsibilities be arranged in private groups? In the public system there is a clear structure and system of rosters, promotion and responsibility - how will this translate in private groups?
8. How will private doctors interact and communicate online and digitally, if they do not have the support of the government and hospital system? Will there be referrals and shared care?
9. How will freelance doctor groups be financed and where will they find their start up capital from? If there is a share ownership, who will own the shares and control the doctors?
10. Will private doctor groups have clout? For example, in medical insurance will doctor groups have enough buying power and negotiating strength to be able to arrange medicolegal cover, settle medical disputes and influence policy?

Are China's doctors happy? A national survey of job satisfaction provides some unexpected results

by MICHAEL WOODHEAD

China's doctors have a lot to be unhappy about. Low pay, long hours, medical disputes that trigger abuse and violence from the public - and daft regulations that force them to publish a quota of 'scientific articles'  every year even when they have no interest in research. 

There has been a lot of talk about poor morale among China's medical profession in recent years, but very little actual research to back these claims up. To address this, the medical online portal DXY conducted a survey in September 2015 that asked a simple question: "do you regret becoming a doctor?"

Responses were obtained from 2,356 doctors, three quarters of whom were male and most were working in tertiary (teaching) hospitals in eastern China (not surprising given that DXY is a medical portal used predominantly by younger and more online-savvy medics).

The survey found that overall almost half of doctors (1146) said they had regrets about becoming a doctor. There was no significant difference between male and female doctors, but there were some interesting trends by speciality and location.

Emergency department doctors had by far the lowest morale, with almost three quarters regretting their choice of career. This is perhaps not surprising as emergency doctors are at the sharp end, doing exhausting shifts dealing with trauma - and being assaulted by stressed out patients and their families with complaints.  Other specialities with poor morale included paediatrics (low pay, high stress when dealing with pushy parents of ailing Little Emperors), obstetrics and gynaecology and oncology.

The specialities with the highest degree of job satisfaction (or least worst morale if you're a glass half empty person) were radiology, TCM and anaesthestics.  The survey also showed that community clinic physicians  also had less regret about medicine as a career - the study authors say this is presumably because they see less sick patients and are more likely to have an ongoing doctor-patient relationship in the community.

Interestingly, doctors in teaching hospitals tended to have better job satisfaction - possibly because the top hospitals have better career prospects and are more professionally stimulating. The doctors in the middle tier hospitals - level 2 - had the worse morale.

Trainee doctors and senior doctors also tended to have better morale whereas mid-career doctors in their 30s and 40s had the worst morale.

On a geographic basis, doctors in the more remote provinces such as Yunnan, Gansu, and Shanxi reported better morale. The survey authors said this was an unexpected results and suggested that salaries were not as important as once thought in job satisfaction.

The study authors say they now plan to publish a more in-depth analysis of the reasons given by the doctors for poor morale.

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."

Why is there so much violence against doctors in China?

by MICHAEL WOODHEAD
As I've said many times on this site, the level of violence against medical staff in China is extraordinary. In one province, Guangdong, there were 25,000 recorded incidents last year alone. Many reasons have been put forward by academics and politicians to explain the epidemic of violence - but there has been little actual study of the contributing factors. Now researchers have interviewed patients and medical staff in seven Guangdong hospitals to get some feedback from the grassroots.

The results of the survey are published in the BMJ this month and one theme emerges: mistrust.

The survey found that there was widespread mistrust of doctors and healthcare staff by the public, based on well-grounded beliefs that there was widespread injustice and commercial bias in the Chinese healthcare system. Patients believed that decisions on their treatment were based more on hospital revenue than need, while at the same feeling resentment that they had to wait for hours to see a doctor for just a few minutes. Costs and financial injustice were a major source of anger: people cited examples of patients being refused treatment - or having treatment terminated due to inability to pay fees.

Doctors also believed there were major injustices in the healthcare system - saying their workloads were far too high and the salaries did not reflect their years of training, long hours and high pressure. They also said that they did not trust patients to behave in a civilised manner, with many being demanding or suspicious.

Patients had little trust in the official dispute resolution systems. They believed that hospitals and law courts were unlikely to give time or serious attention to patient complaints and felt there was little chance of redress for any deficiencies or mistakes. For this reason, patients said they would be more likely to get a result - an apology and compensation - if they used physical and verbal threats, disruption of the hospital and violence to gain attention.

The survey also heard from doctors that their training had not prepared the for communicating with patients or having a good bedside manner.

Both patients and physicians were critical of the government's response to rising violence - namely increasing levels of security guards at hospitals. They said this just inflamed the situation, creating a siege them-and-us mentality and did little to address sudden violent assaults on staff.

The researchers - including several China-based doctors - are openly scathing about the policy response from Xi Jnping and his administration.

"The moral crisis that our study revealed in Chinese healthcare demands a legal and regulatory response as well as a moral one. The Chinese phrase “zhibiao bu zhiben” means treating the symptoms and not the disease. Cracking down on violence and enhancing security measures are unlikely to fundamentally alter patient–physician mistrust and may inadvertently undermine trust."

They put forward three policy suggestions to tackle the climate of mistrust that is driving the violence in healthcare. Firstly they say hospital 'commissions' and incentives to staff for overservicing must be abolished and financial conflicts of interest must be addressed.

Second, doctors and hospital staff need better training in communication, ethics, professionalism and dispute resolution. Finally, there needs to be an atmosphere of trust in which the public are willing to negotiate and seek non-violent solutions, while doctors must be willing to apologise to patient families and accept reasonable consequences for medical error. st.

Similar findings were made in a separate study of junior doctors in three Nanjing hospitals recently. The study found that junior doctors felt extremely frustrated at having studied for up to a decade but having only a lowly job title and poor pay. The doctors said they worked extremely long hours and had high pressure in their work, but also faced poor prospect for promotion or increasing their income. The other main finding was that most junior doctors had experience of abuse and violence from the public, and this was a major contributor to poor quality of life.

"Although Chinese doctors feel relatively unsafe, the phenomenon does not raise sufficient concern from hospital managers . These violent events negatively affect medical workers; for instance, these workers may develop guilt and self-doubt, and such outcomes can reduce the quality of services," the study authors note.

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 appointment "add-on" phenomenon - why China's doctors see far more patients than are booked to see them

by MICHAEL WOODHEAD

A fascinating article run by Xinhua this week describes the so-called "add-on" (加号) system in which doctors squeeze in far more patients than are registered to see them. The official reason for this practice is that doctors often feel sympathy for ailing out-of-towner patient who cannot get a booking to see them that day. However, as the article reveals, the add-on patients are often more to do with doctors making informal arrangements seeing patients with guangxi (connections) or to see patients who have bought their booking slips from ticket scalpers.

To understand the add-on phenomenon you first have to understand how China's medical appointment system works. To see a doctor in China you have to 'register' (gua hao, 挂号) at the front desk of the hospital before you can get to wait at the clinic And with demand for doctor appointments far outstripping supply, this means patients have to queue very early (often overnight) and for a long time to get one of the limited slots available to see a doctor in their chosen department. There are two kinds of bookings: general and specialists.

Typically, a doctor in a  hospital outpatient clinic will work a morning shift from 8am to 1pm. Assuming that he or she works five hours without a break and sees patients for an average of five minutes (far too brief for an adequate consultation), the doctor could be expected to see 12 patients an hour - or 60 patients per shift. However, some doctors are seeing 50% or even 100% more patients per day than their official limit. Why so?

The Xinhua reporter describes the situation in the Chaoyang Hospital dermatology department, where he sees an impoverished family of 'waidiren' (out of towners) sitting with their ailing grandfather in the waiting room late in the afternoon. They are surrounded by their travel luggage and are telling the clerk that they have come from a remote town in a nearby province especially to see the doctor. At 6pm it is time for the doctors to finish their shift, but the doctor agrees to see the old man without a booking as a jia hao (add on).  The patient is given a ticket with the doctor's signature and the clinic chop, and his family are able to take this to the registration desk to get an official registration slip to see the doctor.

The doctor later explains to the reporter that because of his conscience he feels unable to turn away the desperate family who have been waiting there all day. However, he says he nevertheless feels guilty because his 'extended shift' also means that others have to stay behind - the nurses, clerks, pharmacists and security staff.

The doctor says that all departments have 'add-on' patients, some more than others, and each clinic and each doctor has a different policy about how to deal with them. Some doctors and clinics refuse to have 'add-on' patients, even putting up signs saying they are banned, while others reluctantly agree to see some of the more pitiful cases - the elderly and the seriously ill. Some clinics even leave spare room for add-ons and the doctors try to 'triage' their add-on patients to sort out the most deserving and to weed out the tricksters, malingerers and the ones who have paid for their registration.

The situation is complicated because not all 'add-on' patients are genuine. Some are simply putting on an act because they could not or would not wait in line to get a registration ticket. The doctor describes one woman who came to the waiting room with a wheeled suitcase, lamenting that she had  got off the train from a distant town and needed to see the big city specialist. However, an eagle-eyed nurse noted that the woman's suitcase was very light and obviously empty.

The other big problem with add-on patients is that they are exploited by the thriving trade in add-on appointments by scalpers known as 'hao fanzi' (号贩子).  These are the 'black hand' middle men who hang around the hospital lobby pretending to be patients and getting registration tickets which they then sell on illicitly to  patients who have missed out or don't want to line up early in the morning. To combat this, hospitals have introduced a system of ID checks, with registration tickets only valid for the person who has booked them. If the scalpers are unable to get registration tickets directly from the lobby office, they instead try to get bookings by posing as add-on patients. According to Xinhua, the going rate for a scalper-obtained place to see a doctor is 200 yuan for a general appointment and 300 yuan for a specialist booking.

One doctor told the reporter that the fake scalper 'patients' were often convincing or persuasive and he felt too tired at the end of a long day to try work out if an add on patient was genuine or not. The scalpers also cause annoyance to Beijing residents. One local 70 year old man waiting in the rheumatology department told the Xinhua reporter that he had tried to get to see the doctor for three days but had not been able to get a ticket despite queuing for hours each day. He said he resented outsiders and scalpers taking up the appointments that should be prioritised for local patients.

However another doctor hinted that about half the 'add-on' patients were not outsiders or scalpers but connections - guangxi. They would be patients with some connection to an important person, whom the doctor would 'fit in' to repay a favour, build up guangxi 'credit' or perhaps they were just friends or relations. There are also hints that many of the add-on patients use 'hongbao' bribes to be fitted in to see the doctor at the end of his or her clinic. But another doctor said that add-on patients were not a source of extra revenue - quite the opposite. He said doctors were paid a base salary and therefore if they saw more patients they did not increase their income.  He added that it was not uncommon for a doctor to work a five hour shift from 8am to 1pm without a break. He joked that he dare not drink tea while at work as he never even had an opportunity to go to the bathroom because of the number of patients waiting to see him.

For whatever the reason, the problem of add-on patients is obviously a major one - and yet another example of the problems that come from a health system centred on overloaded city hospitals.

CPPCC - what they're saying about health

It's that time of the year again - the Chinese People’s Political Consultative Conference (CPPCC). The toothless talking shop cum fancy dress parade as deputies from around China meet to chinwag and talk up the government's policies. It's an occasionally interesting forum - some grievances are allowed to be aired, but usually only to justify measures that are already being taken.
There has been quite a bit of talk about healthcare this year. Most of the problems discussed are ones that have been given a regular airing on this blog: doctors' income linked to overservicing, excessive workload of doctors and the issue of publish for promotion. On the last point, Prime minister Li Keqiang attended one meeting that heard about the problem of junior doctors having to publish academic papers in order to qualify for promotion. He was told that more than a quarter of doctors had their articles written for them by ghostwriters and agencies. The PM said this was a bad situation and doctor's should be rated on their practical skills, not writing skills.

Our old friend Professor Zhong Nanshan made an appearance at one People's Conference, at which he re-stated his concerns about doctors' pay being linked to sales of drugs and number of procedures and devices provided. He cited the case of one cardiologist who implanted several expensive cardiac stents for a patients who was not even seriously ill. Zhong Nanshan said the problem of doctors' ethic arose because up to 80% of their income was tied to hospital profits. This meant doctors were given quotas to meet and the 'profit-driven' mentality meant that hospitals were more like department stores than public health facilities, he said. Zhong Nanshan said that to end the problem of overservicing there was a need to de-link doctors' incomes from prescribing and servicing levels. Doctors should be paid a higher basic salary that reflected their worth, he said - and he stressed this did not mean a return to the 'iron rice bowl' mentality.

The problems caused by pharmaceutical commission were highlighted this week by the news that GSK is to sack 110 of its employees in China in the wake of last year's massive bribery scandal that resulted in the company being fined  $450 million. The widespread use of bribes, commissions and backhanders caused a lot of pain for the multinational pharma company when exposed. The staff who have lost their jobs may well be scapegoats. The man at the top, CEO Andrew Whitty, kept his job but had his salary package halved to a measly $6 million. Whitty said  “substantial changes” had been made at GSK China, including training for managers in anti-bribery and corruption practices.

Other 'unhealthy tendencies' raised at the CPPCC include the hospital VIP suites reserved for officials and local bigwigs. Professor Huang Zemin of East China Normal University said hospitals had two different worlds, with the VIP outpatient wards reserved for officials being quiet and luxurious whereas the outpatient room for the general public was crowded and noisy. A fair point, but the VIP suites have already been slated for abolition, so he's hardly breaking new ground there.

And also from the CPPCC, a cry for help from the paediatricians.  One of the country's top paediatricians, Professor Shu Xiaomei, told the CPPCC that there was a crisis in paediatrics as very few doctors go into this branch of medicine in China. The reasons are that paediatricians earn very little compared to other doctors, again because they don't prescribe so many drugs or do many procedures). Another reason for the unpopularity of paediatrics is the high workload and the huge pressure from pushy parents - often leading to violence when things go wrong. Professor Shu said there was also no formal training program for paediatrics, unlike other specialties and therefore the speciality was a 'tree without roots'.

The workforce theme was raised by another delegate at the CPPCC, who said that China simply does not have enough qualified doctors to do everything that the public expected of them. His succinct appraisal was that "without more doctors, all discussion about health reforms is empty talk. "
Other CPPCC delegates said that the push to create a primary care system based around community clinics was commendable but facing the major problem of neither doctors nor patients wanting to go anywhere near primary health clinics. Dr Zhao Ping, of the Chinese Academy of Medical Sciences, said patients did not go to local clinics because they had poor equipment and poorly trained staff and could not refer to the best specialists.
"People don't trust these clinics and hospitals. The thing is, people want to go to better and larger hospitals, and so do healthcare workers. We don't have a mechanism in-place to keep our best healthcare workers at community clinics," he said.

But it's not just the CPPCC, here are some other major medical news stories from China this week:

• Two doctors in their 20s have died suddenly of 'overwork' in the last few weeks, prompting some doctors to say that the pressure of work is too high.

• Baidu's CEO Robin Li says Baidu is looking at online appointment systems.

• China's first new advertising law in 20 years is expected to tighten up regulations around advertising of medical products and healthcare services .

• A Fuzhou doctor became a social media viral sensation when he was photographed working while hooked up to an IV infusion. Weibo users praised him for his dedication for working while sick. 

• International medical experts have expressed concern at China's crackdown on ketamine. While the drug is sometimes abused, it is also a very important and safe anaesthetic, and any restriction would be a major blow for safe surgery in poor countries, they say.

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).

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.

The crisis in paediatrics in China

by Michael Wodhead
In the US medical journal Pediatrics this month is an extraordinary editorial about the workforce crisis affecting the discipline of paediatrics in China.

The article written by Dr Zhang Shu-Cheng and colleagues at the Shengjing Hospital of China Medical University, Shenyang, says that few doctors in China want to be paediatricians because of the low pay and high pressure from pushy parents. Dr Zhang says there is a recruitment crisis affecting paediatrics in China, with many hospitals unable to fill positions.

The country has a shortage of 200,000 paediatricians, and this creates a vicious circle by creating additional pressure on those who do choose to work in this field. Because paediatricians are in short supply, they have to see high volumes of patients, leading to more errors and more dissatisfaction from families who feel their child's medical complaints are being rushed and ignored. This in turn leads to conflicts between families and doctors - especially as Chinese culture and the one child policy puts a lot of focus on the health and wellbeing of the child.

According to Dr Zhang and colleagues, much of the problem stems from the low pay and low status of paediatricians. They receive about 70% of the base pay of other doctors, and even less when it comes to the 'grey income' based on sales of drugs and income from procedures and other items. And yet despite these problems - and their causes - being well known to the government, nothing is being done, they lament. Many paediatricians are voting with their feet - moving into better paid or less stressful positions within hospitals, such as lab work or as administrators. Others change to different branches of medicine or leave clinical medicine altogether.

"Despite this crisis, little is being done by the Chinese government to stop the loss of pediatricians, by either increasing their pay, decreasing their job intensity, or attempting to prosecute the violence
committed against pediatricians. The government needs to play a leading role in dealing with this crisis by writing and implementing appropriate laws and establishing fair and objective third party
accreditation bodies. Increasing the investment in pediatrics from public finances, easing the pressure on pediatricians, eliminating the practice of physicians supplementing their income by selling medicines, and increasing pediatricians’ salary levels are possible steps that will lead to
more pediatricians willing to stay in the profession," they conclude.

How many hours a week do Chinese doctors work? Too many.

After featuring many articles from the Lancet's China-themed issue it is only right that I give some attention to an article published by their competitor, the BMJ.

This week a blog post from four Chinese doctors lamenting the long hours they have to work. According to the lead author, Dr Luo Deng (an endocrinologist at the Shanghai Jiao Tong University Affiliated Sixth People’s Hospital) China's doctors work an average of 11 hours a day, six days a week. That's an average - not the maximum. And before you jump in and say that many doctors in other countries work those long hours - remember that Chinese doctors earn about $5000 a year.

The working hours figure comes from a survey of more than 3771 Chinese doctors, which found that 80.5% worked more than eight hours in hospital every day. The exact figures were an average of 11.22 hours per day for 5.62 days a week, with only one day off.

"On top of this, we fear that the increasing number of daily hospital outpatient visits, along with administrative or academic affairs, may further contribute to the imbalance between family and career in doctors’ lives," the doctors write.

The doctors blame the heavy workload on a huge increase in patient consultations in the last decade - up from from 1.21 billion in 2001 to 2.74 billion in 2013. During that time, hospital admissions increased nearly fourfold, but the Chinese government still spends only about 5% of its GDP on health, compared to 8.8% for Brazil and 9.2% for South Africa.

"With a generally high patient to physician ratio in most practices, and near constant patient contact throughout the workday, most physicians find it difficult to take even a short break. Even the public of China has begun to raise concerns about the physical and mental health of physicians; however, these issues probably remain unknown to much of the world," the Chinese doctors write.

They suggest, quite meekly, that the government implement "effective and efficient measures  ... to improve the health of China’s medical staff, and boost their career enthusiasm amid the stressful job atmosphere."

Medical schools in China: outdated and unpopular

Some insider views of the Chinese medical education system have been published as part of The Lancet special China-themed issue this week. The rather gloomy conclusion is that China's vast medical education system is failing to attract good students and failing to produce graduates who are able and willing to work as doctors.

A review article notes that China made some major reforms to medical education in 1998, greatly expanding the number of students to produce half a million would-be doctors a year. However, many of these medical graduates do not enter medicine but take up other careers. Why is this? The review authors say there "is a mismatch of health professional education and employment opportunities".

Another article in the same issue of the Lancet throws further light on the lack of enthusiasm for medicine as a career: Dr Yang Pengfei of the Changhai Hospital, Second Military Medical University, Shanghai, says most doctors now advise their children against taking up a career in medicine and only 7% would recommend it. He cites the breakdown in trust and respect between patients and doctors and the tide of violence against medical staff - 30 killings in recent years by disgruntled patients and their families. Dr Yang notes that even the best medical schools such as Peking Union Medical College are now struggling to attract high quality students.

"The national admission score for a graduate student majoring in medicine has also declined for three consecutive years, according to the Chinese Ministry of Education. It is no longer the best students who go to medical school. This is a growing concern: who will be tomorrow's doctors?" he asks.

The review article says the problem of poor relations between patients and doctors is due in part to the narrow and inflexible education system that fails to instil students with the values, ethos, and ethics of the medical profession and also fails to produce doctors with good communication skills and characteristics such as empathy.

"The curriculum system still focuses narrowly on biomedicine, medical technology, and clinical practice. Pedagogic methods are rigid: mostly teacher-controlled didactic lecturing, which requires rote memorisation by students. The increase of disputes between doctors and patients, and violence against doctors in China might be associated with these deficiencies in education," it says.

Another problem with medical education in China is that it is still rigidly hospital focused and geared towards producing narrow specialists rather than generalists who can work in the community or in rural health.

"Therefore, it is not surprising that the graduates have limited knowledge about primary care services and prevention of diseases."

Will things improve in the near future? It's hard to see how, as huge class sizes are a barrier to more innovative teaching methods such as problem-based learning, and encouraging interaction and discussion.

China's medical schools may need to take a leaf from the book of China's factories. Instead of mass producing unpopular low quality products they could adapt the best foreign know-how and methods through joint ventures to produce a wider range of higher quality sought-after products.

How an uneducated migrant worker became a successful medical journal editor: the publish-for-promotion swindle

 by Michael Woodhead
An amazing and hilarious story in the Chinese Legal Daily this week about how a rural migrant came to Beijing and set up a fake medical journal to publish scholarly articles for senior doctors wanting to boost their promotion prospects.

The young man ran a highly successful publishing operation and made almost two million yuan ($325,000) between 2009 and 2013 when his operation was busted by police. The man called Liu Yang was only 23 years old when he came to Beijing and started working on the reception desk of a hotel in 2009. It was while he was talking to a doctor at the hotel that he hit on his money-spinning idea. The doctor was complaining about how difficult it was to get promotion because of the requirement to have a quota of articles published in medical journals. The problem, he said, was simply that there were too many doctors trying to get published and not enough journals.

Liu Yang had the obvious idea of inventing a medical journal to meet that demand. Despite having only a middle school education and knowing nothing about medicine, he quit his job at the hotel and borrowed  money to buy some basic publishing equipment such as a scanner and large printer. He installed this at his apartment, which would become his editorial office. However, his most important investment was 200 yuan for copies of the leading medical journals, whose style he copied. He also bought a list of top doctors and top hospitals around China.

Awarding himself a doctorate and appointing himself editor and publisher, Liu Yang then wrote to the hospitals on his list and offered the services of his medical journal for publishing. He was immediately inundated with manuscripts from mid-career doctors. As a police investigator later explained to the reporter, the medical career pathway in China is based on publication of scholarly articles for advancement. Promotion from hospital resident onwards is dependent on having a list of articles that have been published in journals. No publication, no promotion.

"Dr" Liu Yang received so many submissions he was rushed off his feet publishing his journals every month, and soon had to call in his wife and other family members to help out. The journals were only circulated to the doctors who had articles published in them. It was essentially vanity publishing. And yet, to maintain some credibility, Liu Yang even started to reject some manuscripts. The fake journal published articles from doctors all over China: the most frequent users were doctors seeking elevation to 'deputy director of department' level, a career step which required many published articles.

At first, the fake journal was a print operation, but doctors then started asking 'Editor' Liu Yang why their articles were not being published online. The fake editor then expanded his shanzai operation online and hired a web designer to copy the website  of a leading medical journal and set up a website for his own fake journal. Now Liu Yang offered digital journal publishing to his hundreds of clients.
In total he published articles by more than 800 doctors, and most were senior doctors at major hospitals, including military hospitals. Most did not realise the journal was a fake operation. A few suspected things were not quite above board, but still paid Liu Yang to publish their efforts because they believed others would not notice.

And for four years they didn't. As a police investigator remarked, there are hundreds of such medical articles and theses published every year and nobody is much interested in what they say - they are simply published to impress hospital administrators. And so until recently nobody was auditing these medical articles or the journals that published them.

However, somebody must have eventually twigged to Liu Yang's ruse. In September 2013 police came calling at the new expanded Chaoyang offices that Liu Yang had expanded into. As cops banged on the door, his wife tried to throw plastic bags of money out of the window, whereas Liu was more interested in trying to save the raw materials for his publishing operation. The police gained entry to the premises and shut down the publishing business, confiscating equipment and 600,000 yuan. Liu Yang and his wife were arrested by police and charged with fraud.

Commenting on the case, a senior doctor at a Beijing Hospital said the fake journal saga highlighted a major fault of the medical career system in China, namely the reliance on having papers published. The doctor said there was enormous pressure on doctors to publish, because promotion offered higher income through access to prescribing a wider variety of drugs. Doctors who were good clinicians but did not publish remained stuck on the lower rung of the hospital ranking and only treated large numbers of patients. Some hospitals even fined their doctors if they did not achieve a quota of published article, he said. And the doctor said the busted operation was not the only fake journal -  he still regularly received emails from dubious sources offering journal publishing services and also ghostwriting services.

Liu Yang's fake publishing operation is now smashed, but the publish-for-promotion system is still intact in China. And while doctors are under enormous pressure to publish, other loopholes will be exploited, corners cut and more scams like those of Liu Yang can be expected to occur.

Shenzhen to pioneer clinical-focused medical training in place of faux-research and academic exams

by Michael Woodhead
Shenzhen is to lead the Chinese medical career pathway away from its traditional emphasis on exams and academic research into a system with more focus on clinical medicine. 
Experts say that medical training and career pathways in China have become dominated by academic achievement at the expense of dealing with patients. This has led to a system in which 'academic essay heroes' get ahead, while those with better clinical skills are overlooked and languish at the bottom end of the career ladder and in smaller hospitals. According to doctors in Shenzhen, the system based on research and academic study is suitable for a few doctors but should not be the backbone of the stem. It puts a huge and unnecessary burden on doctors and also leads to the system in which patients say it is impossible to get to see a good doctor. The academic focus means that doctors build up their titles and certificates, but their clinical skills remain weak from lack of attention.
Under the new system, doctors will be graded according to nine levels of clinical skill and on clinical outcomes and performance. This means that doctors with good clinical skills will be able to achieve career advancement and also increase their remuneration, an article in the Guangzhou Daily says.

Beijing's deregulation of doctors' working locations is a dud

by Michael Woodhead
In 2011, in an effort to improve workforce flexibility, Beijing pioneered a deregulation of medical employment rules so as to  allow doctors to work outside their traditional work unit. 

The move was intended to encourage a free flow of doctors and to encourage medical 'talents' to work outside the public hospital system and perhaps even set up their own private clinics. A kind of medical socialism with Chinese characteristics. However, an article in the Beijing Evening News has highlighted the fact that very few doctors have taken the plunge into private practice - or even left the security of their original hospitals to work at other clinics.

An article in the newspaper says the new flexible working rules were welcomed by doctors and received much positive comment on medical social media forums - but few if any doctors have actually changed their working patterns. Most are still working full time in major hospital clinical departments and doctors seem reluctant to break out from that pattern of work. In interviews, senior doctors say there simply isn't an alternative private framework for doctors to work in - and few doctors are willing to branch out on their own.

They cite several reasons: firstly, doctors are worried about the risks of working outside the established system, especially when it comes to liability and patient disputes. In the public hospital system they are covered by liability insurance and also have the backup and expertise of a major hospital to support them. They feel safe working with trusted colleagues and on familiar ground, and are wary of the quality of working in an unknown environment.

Secondly, doctors face financial barriers to working outside the system. Most are employed full time within the public system and would face a major hurdle in start-up costs to work outside the system - not to mention finding new sources of patients. They also face the major problem of restrictions on medical insurance, which would not cover their work in an unrecognised clinic or environment.

And thirdly, many doctors say that careers in medicine are based on the existing system - training, education, research, peer support, promotion and reputation are all based on working within the current hospital system. Doctors feel they would forsake career advancement if they moved outside the system.

The doctors interviewed by the Beijing Evening News said the deregulation of medical working rules had only legitimised what had already been happening in the current system - doctors moonlighting on weekends and 'after hours' at private clinics or at other hospitals outside Bejing.

The article concludes that much more extensive changes in remuneration, insurance and career paths will be needed beyond relaxing the rules, to encourage doctors to work more flexibly.

Chinese hospitals offer millions to poach doctors from Taiwan

Top medical specialists in Taiwan are reportedly being offered millions of yuan to work in mainland China, and scores of doctors are already taking up the offer to "moonlight" at the weekend.
The Focus Taiwan news channel makes the claim that doctors are being offered as much as 100 million yuan to relocate to the mainland, and there are already 50-60 "holiday knife jugglers" flying from Taiwan to China at weekends to perform surgery or give consultations at hospitals there.
Cardiac transplant surgeon Dr Wei Jeng (left), who is head of the Heart Center at Cheng Hsin General Hospital in Taipei said several Chinese hospitals had made him high-paying job offers in recent times but he had turned them all down.
However, he said many of his colleagues had taken up the offers of  mainland work and the current joke among local physicians that "if you try calling on doctor friends on the weekends, you'll find they are all on the mainland."
While the 100 million yuan claim may be hype, the reality is that doctors in Taiwan earn about NT$8,000 per clinic but can make up to NT$50,000 per clinic in China. And many are doing so. A doctor who used to be a senior manager at a Taiwanese-funded hospital in China said he knew of many Taiwanese doctors earning hundreds of thousands of Taiwan dollars a month by doing weekend moonlighting shifts in China. This has lead to fears of a medical brain drain. Dr Wei said the lucrative offers from China were taken up because the Taiwan national health insurance system paid doctors relatively poorly.
A spokesman for the health ministry acknowledged that 90% of doctors in Taiwan earned their main income from the national insurance scheme and it would be impossible for the health ministry to match the huge pay offers made by Chinese hospitals to Taiwanese medical professionals.
To try retain doctors, the the Taiwan government was planning to set up special medical tourism zones to attract private paying patients from overseas, he said.
Local doctors urged the Taiwan government to make the medical system more attractive to doctors by cutting down on paperwork and improving benefits.

Dr Zhong Nanshan: what's wrong with China's health system and why we need to get doctors on board to fix it

by Michael Woodhead
Dr Zhong Nanshan is one of China's most well known and respected doctors. A respiratory physician and former head of the Chinese Medical Association, he is the 'hero' of the 2003 SARS infection outbreak, and his frank advice is respected by the government. At this week's meeting of the National People's Congress in Beijing, Dr Zhong gave a speech on the current problems with the Chinese healthcare system and the direction of health reforms.

"Today when I heard Premier Li Keqiang's announcement I was very excited, as his words provided a lot of inspiration on the difficult problems we are facing with medical reform. In recent years China's reforms of health insurance and the healthcare system have attracted worldwide attention. But from the public's point of view, there is still the problem of 'difficult to see a doctor, expensive to see a doctor'. Doctor-patient relations are still tense (as the China Hospital Association has recently made clear, hospital doctors and staff have often been the victims of violent  attacks) and hospital staff are not showing enthusiasm or initiative in their work.

For these three criteria, when it comes to health reforms there has been no breakthrough in the last five years, and in fact things have become worse in some areas. Where does the blame lie? The answer is in our major (tertiary level) hospitals.  In these institutions, doctors have not become heavily involved in medical reforms, and this problem is becoming more serious. Look at land reform: this was about the relationship between farmers and landlords, and it was based on respecting the position of the farmer, allowing them to make a living. Likewise with education reform - this was about teacher-student relations and when teachers and schools got better pay, resources and conditions, teachers got more respect.

Why are doctors not enthusiastic for health reform?

Similarly, medical reform will depend on the involvement of doctors. America's medical reforms were about respecting medical opinion and allowing the doctor's clinical judgement to drive the direction of the medical system. I remember in 2012 when Li Keqiang was deputy premier and I saw him at a meeting, and I told him that the most important point I wanted to make was that doctors must be the driving force behind medical reform. However, five years have gone by and it seems that under the present reform system medical staff can see no way in which they can change things for the better. On the contrary it seems that many of the reform programs have an adverse affect on the working conditions for doctors. For doctors it is as if society 'discriminates against them'. And under such conditions, where is the enthusiasm for medical reform going to come from?

As any changes are going to affect doctors' interests, let us first analyse the current situation in regard to doctors' incomes. It is a widely held belief among the public and some government departments that doctors' earn a large amount of extra and unjustified income through what we could call unofficial 'grey channels', and this is seen as outrageous, unethical behaviour. Therefore, before the conference I examined the accounts of the Guangzhou tertiary hospitals. These showed that in 2012 the average official annual salary of a doctor was 41,077 yuan, but the actual annual income for a doctor with all allowances, bonuses and subsidies was 176,320 yuan. For 2013, the average official salary for a doctor was 46023 yuan, but their actual annnual income was more than 190,000 yuan.

Of course this level of income is high compared to the average worker or government official, but it is low compared to the incomes of doctors in other countries. It may therefore be said that this level of income for doctors is reasonable, especially when this extra income comes from government policies as they are applied in hospitals. Here is a typical example of how state-owned enterprises operate to improve performance: hospitals want to increase their income so they increase the number of beds to accept more patients and they increase the number of procedures and tests. On my ward rounds I see many patients who are having unnecessary tests and procedures. One of the main reasons for this is that doctor's income is linked to irrational medical practices - this is a major contradiction within our health system.

Reward doctors for their skills, not for how much they prescribe

My second major point is that a doctor's economic labour value is not reflected in medical fees in China, which are far too low. A doctor's economic value should be related to their ability to diagnose and treat and their ability to give individual attention to a patient based on their skill and knowledge. Unfortunately, in China this is not the case. In the rest of the world a doctor's income depends on their clinical skills, whereas in China a doctor's income is linked to how many drugs they prescribe and how many tests and treatments they order. It is not surprising then, that in China doctors' credibility is called into question. But rather than blame this on a doctor's ethical flaws, we should recognise that this is due to hospital policies that prioritise income and profit and skew the doctor's working patterns.

Too many patients, not enough time

My third point is related to the tense situation in doctor-patient relations. I believe this is 80% due to the difficulty that patients have in accessing a doctor. Owing to the way hospitals operate, doctors are given quotas of numbers of patients to be seen each day. If they do not meet the targets for numbers of patients treated, they miss out on their financial bonus. In other words, the more patients they see, the better. Thinks about this: in half a day a single doctor must see fifty or sixty patients. What does this say about patient access to a doctor and the doctor's 'space' to practice good medicine? The reality for patients is "wait for three hours to see a doctor for three minutes". That just isn't enough time for a proper consultation, and as the consultation time shrinks, the strained relations between doctors and patients increase.

These days in a bid to exploit 'resources' to the full, hospitals are always seeking to increase their bed numbers and they open 'branch hospitals' to increase capacity. While in theory this increases the opportunities for the population to get treatment, the reality is that this increases the hospital income. And the other aspect is that doctors are 'running to exhaustion' trying to treat ever higher numbers of patients. This is not a sustainable model for providing for a community's medical needs.

So we have doctors who see that the government health system cannot provide them with a basic income in proportion to their work and skills. They thus see no benefit from medical reforms so far: they have a negative view, show little enthusiasm and no initiative towards medical reforms. Therefore, as the public should be the target for healthcare reforms, I could set the theme of my speech today as: "Discard doctors as driver of health reform: don't let the medics change the medical reform."

Principles: the need to put more value on health

The way to solve these problems is to change our principles. Today I especially appreciated hearing Premier Li Keqiang's remarks that: "For existing problems the government should look within itself for the causes." I think for health reform we need to look within the health system for the causes of the problems.

Firstly, within both government and society we need to develop a respect for life, to treasure life and health. And if we are to attach importance to preserving life and health we must invest in the health system. From 2005 to 2012 our country made great efforts in health and increased funding for health from 3% to 5% of GDP. However, this is still a lower level of health funding compared to developed countries - in fact we spend less on health by GDP than Afghanistan does. Developed countries spend between 8% to 15% of GDP on health, and we need to aim for that.

But we can't just think of health in economic terms. Health reform must start by putting health and life as a first priority for society. At present in Chinese hospitals the economic value of the healthcare staff is very low compared to other countries. The incomes  of public hospital medical staff are very low and should be higher. Other countries have managed to create good public hospitals systems, why can't we?

Use public insurance funds to improve health services

Of course China has a huge population, and we can't expect our public hospitals to immediately become public welfare providers for everyone. We have to look to the health insurance system for the potential to do that. Since 2011, the national health insurance scheme has been meant to guarantee access to medical treatment and medicines. However the system is fractured and un-coordinated, and those benefits have not been realised. Since 2009, the rural medical insurance scheme has shown good results but these have not been seen with urban insurance schemes, which still have major problems.

Health departments lack the management skills to oversee these schemes, and although the public have paid a lot into these public insurance schemes, the benefits have not been taken out. We should look to these accumulated health funds as resources to fund health reforms. We need to focus on the supply side, not just on patient input and demand. If doctors show good performance they should be rewarded for providing more services. Hospitals should be able to use this insurance funding as a lever to deliver more and better services - but currently the health insurance funds are out of their control and managed by the social welfare department.

The social welfare department does not accept responsibility for health reform and this is a major obstacle to reform of public hospitals and the way that funding is raised, dispersed and linked to performance of the public hospital system. In 2010 there was something like a 7 billion yuan surplus in health insurance contributions - why is this surplus not being used to boost the public hospital provision of services? The health department does not have funding for hospitals - this system needs to be changed - as in 70% of foreign countries where health departments manage public hospitals.

Hospitals should be centres of excellence

Finally we need to improve the education and culture of healthcare staff. We need to have a system based on merit. In most countries, large hospitals are centres for medical expertise and do not deal so much with common, everyday problems. These are dealt with by family doctors or community clinics. Last year the government's health working group made the creation of community clinics and hospitals a priority. I strongly approve of this. Through investment the government should improve the skills and the remuneration and conditions for community clinics and local hospitals. I think the technical and management skills of small hospitals and clinics should be nurtured and overseen by tertiary hospitals, which take responsibility for community clinics. In this way the standard of local clinics could be increased to allow them to cover the same scope of basic care as tertiary hospitals within 3-5 years.

In summary, across the world, the medical profession is regarded with respect in most countries, but China is the exception. The economic value of medical personnel has been degraded, and until this is restored they will not be at the front of driving health reform. The medical staff of Guangzhou University Hospital have great underlying enthusiasm for health reform - it just needs to be shown that reforms will bring them benefits and respect, for them to be positive and actively support them, I believe. I think that in this respect Guangdong doctors will be at the forefront of reforms. We will work together to fulfill what Li Keqiang described as "a solution with Chinese characteristics to the difficult problem of health reform."

Editor's note: This is my translation of Dr Zhong Nanshan's speech that was made at the NPC meeting in Beijing on 5th March, 2014 and published in the People's Daily. It is not a perfect translation, but I have covered the main points as best I can. If you see any errors I will be happy to correct them. The original can be seen in Chinese here.