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?

The top three medical stories from China this week

Medical exam fraud: A medical examination cheating ring has been uncovered in Hebei after a 29 year old woman was found to be taking a postgraduate exam in place of someone else. The woman was arrested after it was found the ID card did not match the details of the doctor who was supposed to be taking the test, who was from Chengdu. The woman said she was paid 60,000 yuan (about US$9000) to take the test on behalf of another person. The woman, who was originally a doctor, said she had given up her job in 2013 after she discovered she could make more money through exam fraud.

Influenza deaths: There have been three severe cases including one death from severe H5N6 influenza in Guangdong and a further death of an overseas visitor from H1N1 influenza, according to media reports. Chinese media said that a a 25-year-old man from Shenzhen, was in a serious condition in hospital. A 26 year old woman died of the same infection in Shenzhen last week, while a third person in Zhaoqing, Guangdong was in a serious condition. Meanwhile a Guyanese man has died of H1N1 influenza in a Miami hospital after returning from China. The infections are presumed to have come from exposure to live poultry and it is not thought there is a high risk of human-to-human transmission.

Air pollution harms fetus: Pregnant women who are exposed to the high level of air pollution in China are likely to have low birth weight babies, a study shows. Exposure to high levels of PM2.5 particles, as found in China's smogs, was linked to a decrease in birth weight and an increased risk of low birth weight, according to a study by specialists at the Guangdong Women and Children Hospital, Guangzhou. The doctors said the effect of air pollution on fetal growth was similar to that seen with cigarette smoke, and was due to immature fetuses being more susceptible to air pollution because they are in critical periods of organogenesis.

Actress Li Bingbing disparages Australian medical system, flies back to China for tonsillitis treatment

by MICHAEL WOODHEAD

Chinese star Li Bingbing has lit up social media with scathing criticism of Australia's healthcare system, claiming in a Weibo post that Australian doctors had been inept and unable to treat her severe tonsillitis. The actress eventually flew back to China where she received intravenous antibiotic treatment at the Peking Union Medical College Hospital and was said to be recovering. The actress claimed she was relieved  to be back in the "good care of the motherland", but her Weibo post triggered an online debate about the merits of China's healthcare system, overuse of antibiotics and how the privileged can jump the queue.

The star of such critically-acclaimed films such as Resident Evil: Retribution had been in Australia filming the scifi movie 'Nest' (about a labyrinth of man-eating funnel web spiders, apparently) when she became feverish with a temperature of 39 degrees. On her blog she said she went to the hospital but was forced to wait two hours to see a doctor, who finally agreed to do blood tests as she suspected she had SARS. However the tests were negative and she was discharged. Li Bingbing said her temperature fluctuated and she 'burned for two weeks', although the photos she posted showed only a temperature of 37.5 degrees.

On December 6 she posted photos on Weibo showing her in the bed of an unnamed hospital, which she claimed was in Australia, with blood stains on the bedsheets which she said was from a botched attempt to insert an IV line. She wrote that the nurse had been unable to insert a needle into a vein despite three attempts and compared her poor technique to the superior skills  of Chinese medical staff. The superstar complained that she had been to three different hospitals without getting any satisfactory treatment for her fever and had therefore returned to China for medical care.

[UPDATE: I have been told that some of Li Bingbing's photos do not match those of an Australian hospital - the equipment is not that used by Australian hospitals. Also, Australian hospital policies require linen to be changed immediately if soiled by blood.]

The Weibo post elicited  a response from an ethnic Chinese  doctor working in Australia, who said that Li Bingbing's claims suggested that she did not understand Australia's medical system and how to seek help. The doctor explained how Australia had a gatekeeper system of GPs, and that unlike China, hospitals in Australia were not the place to seek initial treatment for fevers. He said GPs would usually advise rest and fluids for fevers rather than antibiotics, but he also questioned why the star had a fever for 14 days before seeking treatment. He was unable to explain why Australian doctors might have missed severe tonsillitis and said he did not have the full medical details due to hospital confidentiality regulations.

However, Li Bingbing's management then issued a legal letter demanding that media retract and delete this doctor's article because it was based on inaccuracies. The star claimed to have followed the Australian system rules for seeking medical care  and said she had consulted a "famous" Australian doctor and two other doctors - including GPs. The star's management also strongly denied that Li Bingbing had sought preferential treatment or had been unable to understand English properly.

The saga triggered a wide ranging debate in China's social media, with some netizens saying that the episode was a lesson for Chinese not to "blindly worship" foreign countries and their healthcare systems. Some said it showed that China's doctors and nurses were more skilled, and also that Australian doctors had little experience in treating common illnesses for Chinese patients.

However, other online commenters said that the incident revealed the differences between Chinese and foreign hospital attitudes to use of antibiotics and infusions. They said it showed that foreign hospitals were more strict about antibiotic overuse, and also that they had more careful treatment pathways and did not give in to public pressure for inappropriate treatment. Some critics said Li Bingbing's praise for the "care of the motherland" sounded like government propaganda. However, others used a play on a Chinese saying: "the moon isn't rounder in foreign skies" to assert that  medical care should not be assumed to be better in foreign countries.

Li Bingbing's social media criticism may be a setback for the many countries hoping to cash in on Chinese medical tourists. However, Li Bingbing is not exactly a trusted expert in evidence-based healthcare. According to Wikipedia, she has a qigong practitioner for a 'godfather' who claims to be able to conjure up snakes from thin air and cured her mother of a mysterious disease.

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.

Bigger than Ben Hur: relaxation of hukou system will provide healthcare for China's 270 million floating population

BY MICHAEL WOODHEAD
If the relaxation of hukou (residence permit) regulations announced by the State Council is actually enacted in practice, this will have a profound effect on healthcare access for a quarter of a billion Chinese.

This week the State Council announced that local governments were being instructed to adopt new regulations that will allow nonresidents to get a household registration. This registration will give the floating rural migrants access to basic public services such as education and healthcare, and family planning services. The changes could potentially affect 270 million internal migrants who have moved from rural areas or regional small towns to the larger and more prosperous cities of China. Until now this floating population has been denied access to healthcare facilities in the cities, leading to the development of many unofficial backstreet clinics. The main problem for migrant workers was that their hukou only entitled them to healthcare in their place of residence registration. This also applied to their children.

However, it pays to read the fine print - this does not mean that city hospitals will be immediately swamped by rural migrants seeking healthcare. The new regulations say that city governments should extend 'basic' services only to nonresidents who qualify for residence via a points test based on factors such as length of residence (as much as seven years) and stable employment. Many rural migrants will only qualify for temporary residence cards in the cities, which may limit their access to healthcare.

According to Xinhua, the State Council made the changes because "if these issues can not be effectively addressed in the long-term, it will trigger a series of social risks and contradictions."

However, some media commentators have been asking whether the legislation is premature because local governments are neither willing nor able to provide additional healthcare services to 'outsiders'

The other questions being asked in the Chinese media are: what are the criteria that will allow a nonresident to acquire city registration? Also, what level of services will the be eligible for? Another important question being posed by analysts is what kind of effect the widening of hukou system will have on current city residents? Will they be crowded out of hospitals and healthcare service by the onrush of outsiders?

One expert from the Renmin University, Beijing, also pointed to a potential problem with the loosening of the hukou system: the degrading of the funding base for rural health services. Professor Yang Junhua said many rural areas had already seen huge migration from the their towns and villages, depleting their tax revenue base, meaning they were unable to support services for the 'left behind' residents who tended to be either older and retired or young children. Allowing rural residents to switch their hukou to cities would further undermine the viability of rural healthcare services, he warned.

Professor Yang also predicted that there would be resistance on the ground from city governments to implementing the new regulations, and thus the central government would have to be strict in monitoring and enforcing the rollout of any hukou reforms.

Nevertheless, if fully implemented the new residency regulations are a 'game changing' step for China and have major implications for healthcare. The 'floating population' have long been neglected in terms of healthcare and many of the rural migrants in cities have poor healthcare as a result: unable to access health services they have missed out on basic services such as vaccination, leading to outbreaks of infections such as measles. The new residency rules could have more of an impact on China's healthcare system than the recent more widely publicised two child policy.

Shanghai hospitals to ban antibiotic infusions for coughs and colds

by MICHAEL WOODHEAD
Not before time, some of the more advanced and enlightened provinces of China are to ban the widespread practice of giving patients antibiotic infusions for common colds.

Visit any emergency department or outpatient department in a major Chinese hospital and you will see row after row of patients hooked up to IV infusion lines. These are people who have coughs, cold and fevers and are given intravenous antibiotics as routine therapy. In most other countries this would be seen as an absurd, unscientific and harmful overtreatment, but in China it is the norm. There is an almost superstitious belief among Chinese people that an infusion is a panacea.

Many doctors have spoken out against the practice but until now hospitals and health authorities have done nothing to curb the practice. That may be all about to change. The Jiangsu health department has put hospitals on notice by saying that from 1 July 2016 infusions will no longer be permitted as routine therapy in outpatient departments of major hospitals (2nd and 3rd level). This will include city hospitals in cities such as Shanghai.

In a recent interview with People's Daily, Xuzhou Medical College Professor Wu Yunming said the most appropriate treatment for a cold was to take a simple antipyretic such as aspirin, rest and drink plenty of fluid.

"Sick people going to hospital for an infusion has become a long established bad habit, which is one of the important factors for antibiotic drug misuse," he said.

Professor Wu said it was a practice that must be stopped but it would require a change of thinking among the public as well as among the medical profession.

He said strict rules were needed to ban infusions because although doctors were aware that they were inappropriate, self regulation and guidelines had failed to curb their use. Professor Wu said it was typical for an outpatient department to have 200 patients in a morning having infusions - and not unknown for up to 700 patients a day receive such treatment. This was highly profitable for hospitals, which charged 100-200 per infusion, he said.

"Hospitals are businesses and infusions represent a significant source of revenue for them," he noted.

A reporter who visited a major hospital found that healthcare staff were sceptical about the planned ban. They say their was widespread patient expectation and demand for infusions, and if tertiary hospitals did not offer them then patients would simply go to smaller hospitals or local community health clinics that would still provide them.

Professor Wu said rational use of antibiotics was an important issue because antibiotic infusions could cause anaphylactic reactions, increase resistance and also cause other major side effects on the kidney and liver. Infusions also wasted a lot of workforce capacity and resources as nurses had to set up and monitor infusions. He said there needed to be a system-wide plan and implementation of the infusion ban, with an emphasis on social responsibility for hospitals and professional responsibility for doctors.

A spokesman for the Jiangsu department of health said it would be issuing a 'blacklist' of more than 50 medical conditions for which infusion was not permitted.

China's pharma companies take a stake in public hospitals. What could possibly go wrong?

by MICHAEL WOODHEAD
China's not-very communist health minister Li Bin wants to see hospitals turn to "social capital"(ie private investors). And it is slowly starting to happen. China's 'public' hospitals are currently in a strange place - they are essentially state-owned for-profit enterprises, but bound by an odd mix of rules and regulations that keep some prices in check and yet which allow rampant price gouging and overservicing in areas such as pharmaceuticals. Not for nothing are pharmacies know as the 'gold mine' of hospitals.

To try get rid of the obvious incentives for hospital doctors to overprescribe the government is currently phasing in a ban on drug commissions. They are trying to de-link income from drug sales and hospital revenue.

However it's not clear to me how this squares with the trend for China's pharmaceutical companies to go into partnership with hospitals, and essentially to become their operators. Take the recent deal by the Guangzhou Baiyunshan Pharmaceutical Group to invest in six hospitals in the obscure Shandong city of Jining. The joint venture covers six main hospitals with around 6000 beds and a total annual revenue of 2 billion yuan.

The local health department has 49% stake in the new Jining health provider company, while the pharma company has a 33% stake in return for 5 billion yuan investment. Other stakeholders include investment companies, with between 15% and 2% interests.

Analysts say the new joint venture will allow industrial groups to make profits from controlling supplies of pharmaceuticals as well as medical devices, supplies and equipment. I'm no health economist but I can't see how allowing a pharma company to own and operate all of a city's hospitals is good for the patient. Who decides which drugs are made available at the hospital - and what happens to the competitor products? Also what is to stop overservicing, as we have seen so evidently a problem in the current system?

As a commentator in Caixin magazine concludes:

"With deals like this we need to first be clear what is the purpose of the restructuring of public hospitals, and through the restructuring of what kind of results you want to achieve? These issues need further study and discussion. "

China is crazy for medical apps

The latest medical app craze in China is iBaby, developed by an entrepreneur from Harbin to provide antenatal, childbirth and childcare advice to Chinese women. The creator Lu Guotao featured on a recent Apprentice-style TV show on which he demonstrated how his app can link women up to advice via video and online help from obstetricians. Lu turned down offers from investors and went it alone to market the app, which he says now has tens of thousands of users in 31 provinces. Lu says he has had 10,000 obstetricians sign up to provide medical advice online via the app. The one stop platform for pregnancy advice also links women up with local clinics and offers links with merchandisers for pregnancy wares.

Lu says he was already a successful businessman when his wife became pregnant, but they were so busy attending to their work that she lost the baby through a miscarriage. Lu turned his grief into an energetic mission to help avoid such incidents again, by providing accessible information, advice and contacts for prospective parents.

He says the huge success of the app is not surprising given China's move towards relaxing the one child policy and also the opening up of the healthcare system to private investment and more flexibility in doctor roles.

The app has received backing from national obstetric experts including Professor Liu Xinghui, director of the West China Second Hospital, Sichuan University, Chengdu. Professor Liu offers weekly online lectures via the app. She says women can access a wide range of obstetric experience via the app.

Medical news from China: 7 stories that made the headlines this week

1. Nurses in Wuxi are being taught lessons in etiquette by air hostesses. The aim of the program is to make the nurses more customer focused and dispel their image as unfriendly.

2. Acute kidney injury is common in China with 700,000 deaths a year. Researchers from the Medical College of Nantong University found that acute renal impairment went undiagnosed in more than 70% of cases, and was often caused by patients taking nephrotoxic drugs or TCM.

3. A female neurologist in Wuhan is suing a woman for slander and damage to her reputation after the women mounted a four year campaign to blame her for her mother's death. Dr Mei Bin is suing the woman for 5000 yuan in compensation and apology after the woman spread false stories about her and claimed she was unqualified for her post. Dr Mei Bin said she had nothing to do with the care of the women's mother and the allegations against her were false, probably related to a doctor with a similar name in another province.

4. Researchers from Zhejiiang report a case of human to human transmission of H7N9 influenza in hospital from Feb 2015. Both men died, according to a report in the BMJ.

5. Health inequalities: hospital mortality rates are 40% higher in rural areas compared to the cities, a new study shows.

6. About 44% of Chinese women take Traditional Chinese Medicines during pregnancy, the most common being Angelica sinsensis (29%), Ziziphus jujuba (21%) and Dioscorea opposita (13%). Most women used TCM on the advice of their mother or mother-in-la, according to the survey of 700 women in Sichuan. The researchers warned that TCM may cause fatal hepatic and renal effects and some are adulterated with lead or pesticides.

7. A Beijing medical school has started a program to train more psychiatrists to help overcome China's widespread lack of mental health clinicians. The Beijing Huilongguan Hospital Clinical School of Peking University aims to help train several hundred psychiatrists over the next decade. China currently only has 20,000 psychiatrists and needs at least three times that number to match other countries.

Antibiotics in China: not quite there yet

by MICHAEL WOODHEAD
Regular readers of this blog will know that antibiotic misuse is one of my real bugbears about medicine in China. Seeing rows of patients in emergency departments routinely hooked up to infusions of broad spectrum antibiotics for fevers is a symbol of everything that is wrong with healthcare in the PRC.

Well it seems that I'm in good company in deploring this unwelcome practice. As part of Antibiotic Resistance Awareness Week, the World Health Organisation has taken China to task for its misuse of antibiotics. In a new global report it singles out China for having particularly poor usage and knowledge of antibacterials. A survey reveals that more than 60% of Chinese think, incorrectly, that colds and flu can be treated by antibiotics. A similar proportion have used antibiotics in the past few months and one in four bought them over the counter rather than obtain them on prescription. And while 67% were aware of the term ‘antibiotic resistance, few realised that cutting down on antibiotic use was the way to tackle it.

The WHO states that China is one of the worst offenders for antibiotic misuse and blames the lack of awareness among the citizenry for this problem. For a country that prides itself on such a good education system, how can Chinese be so badly informed about such an important matter?

The head of the pharmacy department at the Beijing Union Medical College Hospital, Zhang Jichun, says many Chinese demand antibiotics as a "quick fix". At the hospital if doctors say that antibiotics are inappropriate for patients with a fever or a cough they are rebuked with: "my illness so bad, why don't you give me an infusion for it?" Doctors say patients accuse them of not taking their illness seriously and demand "give me an infusion quickly so I will recover quickly and can get back to work!"

The WHO says it hopes the new report will raise awareness about antibiotic overuse and the risk of resistance in China. I'm not holding my breath.

Top 10 hospitals in China

by MICHAEL WOODHEAD

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

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

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

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

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

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

Dodgy hospital uses call centres to lure bumpkin victims

by MICHAEL WOODHEAD
A backstreet private clinic in Beijing is using call centre staff posing as doctors to lure unsuspecting victims to have expensive and often unnecessary medical procedures. In an expose, a Beijing Times reporter spoke to call centre staff for the Beijing Sande Weiye (三德伟业) clinic, who described their high-pressure sales tactics to bring patients in for high tech and often unproven treatments such as 'stem cell' technology for arthritis.

The call centre staff said they were given a script and a template to respond to phone inquiries coming from people who had been deceived by fake websites and Baidu advertisements that claimed their 'hospital' was affiliated with prestigious major hospitals in the capital. When answering calls, the sales staff said they were doctors but in reality they were unqualified and just ran through a script whose aim was to convince callers that they could jump the queue and get access to top specialists at the city hospitals. Most of the callers tended to be gullible out-of-towners who were seeking treatment in the capital rather than rely on the more basic and underfunded rural hospitals.

Sales staff told the reporter that they were pressured to get the caller's mobile, after which they would make a series of promises and phone calls to establish a relationship with the prospective customer. They were paid on commission: 2 yuan for getting a call, 20 yuan for getting a registration (ie phone number and verbal contract) with the 'network' and 60 yuan for a hospital visit. The sales person also got a cut of the treatment fees and drug fees. A successful telesales operator could make 5000 yuan in this way. The treatments offered were often high technology - such as joint replacement - and were offered regardless of whether they were really appropriate for that patient.

When the reporter visited the 'hospital' he found it to be just a standard clinic with unscrupulous doctors offering treatments that were much higher in price than the same treatment in public hospitals. A knee replacement, for example was priced at 60,000 yuan.

When the reporter informed the top three hospitals that their name (and reputation) was being hijacked to promote a bogus clinic they said they did not have the staff or resources to chase up the many such cases they heard about from complaints. They suggested the fraud be reported to the Public Security Bureau, but the PSB said they would only follow up complaint from people who had been swindled and who had evidence to show criminal behaviour. They instead suggested that the reporter called the consumer affairs bureau.

The Beijing Industry and Commerce Bureau  told reporters that any company making false propaganda, should be reported to the bureau's hotline and would be investigated, with fines and business license suspensions for offenders..

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.

Plans for online pharmacies hit a roadblock in China

by MICHAEL WOODHEAD

It was pitched as the great disrupter of the Chinese healthcare system: online sales of prescription drugs would reduce distribution costs, improve efficiency of the supply chain of medicines and be great for consumer choice, convenience and affordability. Unfortunately, despite a lot of official hot air, nothing has actually happened.

In May 2014 the Ministry of Commerce released a draft plan to 'open up' the pharmaceutical market to allow online sales. But since then there has been nothing heard from official sources about when and how online sales of prescription drugs will be permitted. While some of the big players such as Alibaba are positioning themselves to be online pharmaceutical vendors, it is still just talk: selling drug online is still illegal and insiders say the government is now dragging its feet on plan to open up the market. The pressure is coming from vested interests in the pharmaceutical industry and also from the powerful hospital lobby.

According to the Commerce Department, online sales of drugs are growing at a phenomenal rate. They say revenue has increased 50% in the last year and there are now 425 companies competing to sell pharmaceuticals online in a 4 billion yuan market. However, at present only non-prescription drugs can be sold online - that market is worth 200 billion yuan and only 2% of it is online. The much bigger market - the 800 million yuan prescription drug market - is still out of bounds. Analysts predict that up to 30% of drugs sales could move online - so there are huge stakes involved for those who win and lose on online pharmaceuticals.

According to Caixin magazine, plans for online sales of pharmaceutical are being opposed by those who say government-run hospitals will lose one of their main sources of revenue if this goes ahead. The China Pharmaceutical Association warns that prescription drugs must be dispensed under the supervision of a pharmacist to ensure quality of the product and also to ensure that it is going i the right for to the right patient.There is no guarantee that this will happen online, they say. They also point to the fact that online purchases of drugs will not qualify for heath insurance rebates - a crucial factor for most patients, who expect to get some or all of the cost of their medications reimbursed by their health insurance.

Hospital-based pharmacists have also attacked the proposals for having little real-world benefit. They say there is no clear evidence for the benefit of online sales of drugs from a clinical perspective. Are online sales of drugs being promoted to improve patient's health, or just as a trend or a money-making venture, they ask. They have called for a responsible "opening up" policy towards online pharmaceuticals from the government.

In the meantime, it seems China has stalled on the issue of online pharmacies.

Uber Doctor? China's version of the taxi app just launched a home doctor visit service.

by MICHAEL WOODHEAD
The company that runs China's answer to the Uber app - DiDi, has just launched a home doctor service, called DiDi Doctor. 
A pilot program of the doctor-hailing app is being run out in four cities: Beijing, Shanghai, Hangzhou, Nanjing. The services promotes itself as offering a renowned surgeon for private consultations. In its first few days it got 20,000 calls - but only treated 40 patients. The service is being run in cooperation with Ali Health, and is currently being offered for free - for those who can get through. However, feedback on the service has been mixed, with consumers doubting the experience of the doctors involved, and questioning whether they are even entitled to treat patients outside of hospital.

A pregnant woman called Chen who used the service in Shanghai, said she thought it would offer a way to avoid the long waits at the tertiary hospital. However she found that the doctor dispatched was a cardiologist with no experience in obstetrics and gynaecology. The doctor also told her that he was only allowed to give general advice and could not write prescriptions for pharmaceuticals - only minor medications and supplements. It seems the DiDi Doctor staff are on secondment from private hospitals, but they do not have authority to practice medicine beyond their registered place of work. Users also questioned the calibre of he doctors involved, saying that good doctors were already in high demand, seeing 30+ patients in a morning - why would they spend a day driving round seeing only four or five patients. Users also questioned the business model, saying they would pay about 200-300 yuan to see a doctor in a public hospital - how much will DiDi Doctor charge when the service is beyond the test stage?

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.

Hospitals heed Xi Jinping's call to make use of "social capital", then rip off investors

by MICHAEL WOODHEAD
One of the cornerstones of Xi Jinping's healthcare reforms is the urging of public hospitals to take advantage of "social capital" (ie private investors) for future expansion and development.

Unfortunately, in China's murky and non-transparent climate of investment, things are quickly going wrong in predictable ways. A hospital in Jiangsu now owes its mom and pop investor almost a billion yuan, according to reports in the People's Daily. The Workers Hospital of Suqian asked locals and employees to put their capital into the hospital's investment fund and promised regular interest and dividend payments.

In 2012, a man called Chen heeded the call to invest in the Suqian hospital to help fund the building of a new hospital and to further develop and expand medical services. The hospital guaranteed a fixed income and this was backed by the local government. Mr Chen put in his 2 million yuan retirement savings and was initially  pleased with the interest payments he received on a regular monthly basis. In fact, Mr Chen was so impressed he persuaded his family and friends to invest their money in the hospital as well. In addition, local TV advertising that was aired to promote the fund resulted in more than 2000 small time investors putting close to 900 million yuan into the Worker's Hospital Investment Fund. However, things started to go wrong in April this year when the hospital defaulted on its interest payments. Investors who asked why they hadn't received their usual payments were fobbed off with non-commital replies.

However, as public complaints and protests increased, the local police and authorities have opened a financial investigation into the missing monies. So far they have found that there is not enough money to pay the interest and also not enough to repay the principal sums that were invested and which most investors are now demanding be repaid.

Several of the hospital financial managers have been detained for further investigation and the local authorities say they are now tracking a number of unauthorised financial investments. It looks very much like the Suqian people have had their social capital blown on the roller coaster Chinese stock market that crashed so spectacularly this year.

Putian cartel?

Meanwhile, China's private hospital market has started to take off in a big way with more than 8000 hospitals and clinics in the loose "Putian Network" forming an procurement alliance. The Putian hospitals network is a loose association of healthcare establishments set up from the 1980s onwards by entrepreneurial families from the Fujian town of the same name. Although suffering from a poor reputation for marketing of dodgy services such as fertility clinics and cosmetic centres, many of the Putian hospitals are trying to transition into more respectable establishments. Several of the hospitals have formed groupings and sought investors through IPOs. Now the Putian group hospitals say they are seeking to consolidate and form buyer's groups to give themselves greater purchasing clout. However, Putian hospital are still suffering from a credibility after being banned from Baidu for their dodgy advertising claims.

Having a break

No posting until the end of September: I'm cycling in Heilongjiang and Russia.

Science Communication in China

by MICHAEL WOODHEAD
On this blog you'll often see me harking on about the lack of health literacy among otherwise well educated Chinese people. The media in the west are always looking enviously at China's education system for the high marks in subjects such as maths and science. How is it, then, that Chinese people have such backward views on scientific matters such as antibiotic overuse and resistance? Is there no equivalent of Mythbusters in China?

One factor in the lack of scientific literacy in China is the poor level of science communication. There is little real popularisation of science in China, and few science communicators in the public eye. The reasons for this are well illustrated in an excellent - if somewhat academic - article in the journal Public Understanding of Science this week. Written by Zhang Yueyue (currently at the University of Kent, UK), the article entitled "The Credibility Paradox" explores why China's scientists don't connect with the public - and why the public don't listen to them.

The basic answer is that like many things in China, science is heavily politicised and a no-go area for individuals who are not officially approved. Zhang says that what little science communication there is in China is a "top down" process and is mostly concerned with policy. Science has long been seen as an instrument of Party policy in China, and its role is to serve politics. There is no popular participation in science debate, and no debate or discussion about science beyond the most basic principles.

In the west, we are used to seeing science communicators in the media who are independent and who express their own views and theories about scientific matters. Science communicators are often sceptics and are ready to challenge the official line - whether it be government, business interests or popular misconceptions and quackery. In China, it is a very different situation. Commentary on scientific matters is the preserve of a few "Big Experts" who have official blessing. There is little or no role for grassroots or frontline workers in science fields such as the biomedical sphere. There is no tradition of independent or dissenting thought in science, and there is little willingness among scientists to come forward and engage the public to popularise science.

And because science is seen by the public as being part of the political process, there is little trust or interest in what science commentators say. The top-down official model of science communication has little credibility with the ordinary Chinese citizen - they are alienated from science and there is no engagement.

This lack of interaction is a two-way process. Zhang's journal review describes the feedback she got from nine biomedical scientists who were interviewed abut their views on science communication. Most said they had little interest or willingness to get involved in public discourse or engagement around science. They did not see it as their role and would not want to take on the role.

When asked why, the scientists said they did not want to get involved in politics or become labelled as "stirring up trouble" by starting a public debate. Most scientists also said they were not qualified or entitled to talk about science in any official capacity as they were not "Big Experts" only "frontline workers". They would not comment about science in online forums or by writing articles because this would bring pressure from their institutions and have an adverse effect on their careers, they said.

Another reason that scientists cited for not getting involved in science communication was that experience showed them that nobody paid attention to what they had to say. They remarked that there were few good outlets or forums for science communication, and they were kept "out of the loop" by leaders and managers on science policy, so there was little point in discussing it anyway.

Interestingly, many scientists said they did not want to be associated with official science communication because they believed that science spokespeople had little credibility: "Nobody would listen to you or believe you" was one comment made.

However, the scientists said they did love talking about their work and explaining their scientific methods on an individual basis in informal situations. In other words, they were happy to be science communicators so long as they did not have their official hat on.

Ultimately, the lack of science communication means there is little understanding of science and thus poor science literacy in China, the scientists concluded.

In practical terms, this means that when biomedical scientists in China comment publicly about health and medical matters they are seen as having little credibility, and are viewed as simply spouting the "official line" or propaganda - and not to be trusted. And even when they are believed, their views and outlook are often not understood or given much attention.

This may explain why China's healthcare system is often dominated by unscientific practices - and why China's "medical experts" have little credibility in the public eye.