Tuesday, 30 June 2015

Starlet snubbed; swears at surgeon

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

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

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

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

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

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

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

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

Sunday, 28 June 2015

Healthcare reform in China - The Five Reforms and why they will fail

by MICHAEL WOODHEAD

As part of its latest round of healthcare reforms the Chinese government has released  a handy guide to the five top things it is doing to overhaul the creaky hospital system. The snappily titled "Guiding Opinions on Pilot Comprehensive Reform of Urban Public Hospitals" is really just a wish list for what the government would like to  see happening in the public hospital system.

Bear in mind that in China a "Public Hospital" is not  a public hospital as we would understand it in Britain or Europe. It's not a government-funded hospital that provides universal care. No, it's a state owned enterprise that runs a user-pays health institution. No money, no treatment. It's true that most people have some kind of government-subsidised health insurance that may cover some of their medical bills, but here again the public hospitals have a monopoly on that income - until this year private hospitals were not eligible for medical insurance rebates.

Anyway, all that is changing with the new Five Reforms:

1. Management Reform

The government says hospitals must adopt a more independent and accountable management system - recruiting outside experts and taking on board evaluation and performance review systems. They must start to subject themselves to outside scrutiny from consumer and industry groups and  - here's the killer - be transparent with their data. In other words, reveal their costings (insurance companies will love this) and their activities. A big ask. Expect massive resistance.

2. Revenue Reform

Hospital must stop relying on profits from sales of drugs and medical devices for their revenue. At the moment hospitals get 40-60% of their revenue from markups on drugs, medical equipment etc, and only a small proportion from medical fees and government subsidies. The central government wants to reverse that, and is going to ban drug commissions. To make up the lost revenue the hospitals must increase medical fees. Patients won't like that. There have already been riots in pilot trial sites in Sichuan by kidney dialysis patients who saw their cost of treatment go up 200%. The local government backed down.

3. Performance Reform

Hospitals must ditch the current system that forces doctors to overservice in order to achieve their bonuses. They must ditch the contracts that link doctor's remuneration to prescribing and procedure numbers, and replace it with a performance system based on clinical outcomes, service and efficiency.

4. Gatekeeper Reform

The government wants a primary care gatekeeper system and says tertiary hospital must stop being the One Stop Shop/First Port of Call for all and sundry.  Medical insurance policies are to be changed to force patients to attend local community clinics for minor illness and then be referred to local hospitals before going to a major tertiary hospital. The  major city hospitals will be reserved for more advanced and complex care patients. They must stop offering outpatient care for minor illnesses. This will take some getting used to because at the moment all Chinese make a beeline for 'the best hospital' as soon as they have a cough or cold.

5. Private Interest Reform

State-owned hospitals must be opened up to outside private business interests - the so-called 'social capital'. Private companies must be allowed to take on major roles within hospitals, along with insurance companies, and other medical foundations. Most importantly, they must have access to health information data.

The long and short of this guidance is that the closed and tightly-controlled monopoly situation for state owned hospitals must be bust open. At the moment, state-owned hospitals are the empires for local government bureaucrat-business chiefs. They jealously guard their business and their revenue stream - which is patients and the drugs and treatment they receive.

In an interesting opinion article in Caixin this week, Tsinghua University health economist Li Jiangge says that previous efforts to reform the hospital have failed because they simply have too much power and have too much to lose. He cites the example of government programs to provide  affordable treatment for cataracts. Although the central government provided generous funding to set up cataract treatment programs, most local governments blocked these projects in their areas because they would lose the lucrative income from doing the operations in their own hospitals. In other words - hospitals will block anything they see as competition or which undermines their own services. Likewise with kidney dialysis: China has 3 million people with renal failure needing dialysis, but only 400,000 get dialysis. The remainder go untreated and have early death because public hospitals will not allow private operators to enter this area and compete with them.

As Li Jiangge says, private investors and public hospital managers are "strange bedfellows" with conflicting and competing interests, who cannot be expected to co-operate. The few attempts at encouraging private industry to go into partnership wit public hospitals have not been a great success, he says.

Li Jiangge says private hospitals will only flourish when they are independent of the public system and have access to the same advantages such as medical insurance rebates and access to health data. Furthermore, he says private hospital development has been held back by lots of regulations that make them subject to local government control - including many "not-for-profit" rules. He says private companies should be allowed to do what they do best - make profits and take them away. The role of government should be to focus on "public health" matters such as disease control, vaccination and basic health services, he argues.

Monday, 22 June 2015

If you think Dr Google is bad ... 'Dr Baidu' leaves woman 30,000 RMB out of pocket for botched operation

by MICHAEL WOODHEAD

[This is a long article explaining how Baidu paid search has contributed to the proliferation of a wide network of shonky clinics for 'sensitive' conditions such as STDs, Infertility and Gynaecology].

A Shanghai media outlet has exposed what it says is the all-too-common practice of dodgy hospitals paying large sums of money to get the top Baidu search rankings - and then overcharging patients for shonky treatments. The IT News cites the case of a woman called "Snow" who paid 30,000 yuan ($5000) for an operation to treat uterine fibroids at the Shanghai 85 Hospital after seeing it came top of the rankings when she Baidu'd her symptoms. However, after her condition worsened and the woman went to another public hospital, she found that she had been grossly overcharged for unnecessary and harmful treatments.

The article then reveals that  dubious private clinics and hospitals such as the 85 Hospital pay Baidu as much as 90,000 yuan ($15,000) a day to be listed as the top result for 'gynaecology hospital' on China's most popular search engine.

The article says its undercover reporter discovered that the 85 Hospital had set up 13 different Baidu accounts to pay for the top result ranking for various medical keywords. The information accompanying the search results claimed that the hospital was one of Shanghai's most prestigious institutions with a history of 66 years. In reality, however, the '85 Hospital' was just one floor of a PLA-run hospital that had been leased by the Putian Group of private clinics.

The trouble for the 43-year old Ms Snow started in 2014 when a routine work medical revealed she had uterine fibroids and an ovarian cyst.  When she searched on Baidu for these symptoms she saw the 85 Hospital had the top ranking and its gynaecology department was supported by many glowing testimonials.

When she consulted a doctor there, at a cost of several thousand yuan, she was told that the fibroids and cysts were worse than she had been told, and that she also had other pelvic problems. However, the doctor told her not to worry and reassured her that these could be cured with surgery. She went ahead with the surgery, being billed 17,000 yuan, of which she could only claim 3000 on her state medical insurance. (She was told beforehand that it would only incur 2000-3000 yuan out of pocket costs). Ms Snow was also called back for repeat follow up treatments to diminish inflammation, at a cost of 800 yuan per session. Her total outlay was 32,000 yuan.

Two months later, Ms Snow still had bad pelvic symptoms and went for a second opinion to the reputable Fudan University hospital gynaecology department. The doctor there told her she had premature menopause, and the condition was likely brought on by her recent operation. He was unable to judge on the appropriateness of her treatment because she had no medical records. However, when she mentioned the 85 Hospital he shook his head and said it sounded like a private  'contract clinic'.

When Ms Snow looked back on her experience at the 85 Hospital she began to suspect it was strange - as she had had to register in a separate office from the usual public patients - and all the offices and clinics were separated on the 4th floor. She had been accompanied by a nurse the whole time  to pay for treatment, and had been prevented from mixing with other patients. However, it was odd that she she had not been offered overnight recovery time at the hospital, which is usual practice for such a serious operation.

The doctor explained that gynaecology clinics were known as 'gold and silver' clinics to unscrupulous operators because women were embarrassed to talk about such complaints treatments and were easily persuaded to have unnecessary treatment.

When the IT Times followed up her case, it discovered that all the gynaecology keywords in Baidu automatically led to the "85 Hospital". It found that visitors to the 'public hospital' were asked about Baidu and then directed to the 4th floor where they were registered at a separate office from public patients. In the waiting room, the undercover reporter met other women who said they had been charged large amounts of money - typically 7000 yuan - for simple treatments that would usually only cost 2000 yuan in a public hospital. All of them had been directed to the clinic from Baidu and many had already spent several thousand dollars. They believed the clinic was reputable because of its high Baidu ranking and the testimonies there.

The undercover reporter was seen by a female Dr Huang, who had several professional certificates on the wall. After a cursory examination, Dr Huang referred the female journalist for an ultrasound, which shes aid showed major pelvic abnormalities. The treatment would involve surgery and the undercover 'patient' was advised to make a booking. However, when these scan results were taken to another hospital, the doctors said the scan was normal.

When the IT News reporter tried to make a complaint about the 85 Hospital at the city health department, she was told that the hospital was PLA controlled, and the department had no supervisory role over the hospital or the staff who worked there.

The reporter then investigated why the hospital came top of the Baidu listings, and found that the listings were all marked as 'promoted', meaning that they were effectively paid advertisements.  Strangely, there were many listings under different addresses but all led ultimately to the 85 Hospital website and 'information inquiry' hotline.

A 'WHOIS' search on the different web addresses showed that the registrant was a group know as the 411 doctor's group, which in turn was linked to the PLA 411 Hospital. An admin address was traced by a reporter to a backstreet cosmetic surgery clinic called the "Meilian Beauty Centre". These clinics were in turn linked to an investment group know as the Shanghai MingAi Group. Undercover enquiries about employment opportunities with this group were refered back to the parent company in Taizhou, Jiangsu.

According to the company records, the shareholders are Ling Fengyu and Sun Jinping. They were linked through another company, Shanghai Venus, with someone called Lin Chunguang. This in turn is listed as the same address as the Putian Medical Company boss. Further checking showed that all the former clinics and hospitals are listed as Putian subsidiaries.

This situation resembles the 2007 incident over a 'fake' Harmony Hospital. At that time a Shanghai Harmony Hospital was set up, which many assumed to be a branch of the renowned Beijing Harmony Public Hospital. However, it turned out to be a privately run venture recently set up by Putian's Lin Chunguang. The hospital was de-registered after it was found to have been providing overdiagnosis, overtreatment and overcharging of female patients at its Fertility Clinic. At that time Putian's Lin Chaungwang was spending hundreds of thousands of yuan on advertising for his clinics. All that has changed in the last eight years is that he is now channelling this advertising through online sources such as Baidu.

Investigations by IT News found that the 85 Hospital is paying about hundreds of thousands of yuan in fees to Baidu trough 13 different advertising accounts for the medical keywords related to gynaecology problems. For every click by a consumer on a keyword, the company must pay several hundred yuan (145-212RMB). In addition, the 85 Hospital has paid Baidu for a prestige 'verified' title  on listings, which costs an additional 5600 yuan per title.


When the reporter asked about this 'V' verification procedure with Baidu's Zhendao and Guojing Information agencies, she was told that PLA and Armed Police institution were not allowed to undergo such verification, but this could be worked around.

On the Baidu site the reporter scrolled through seven pages of search results for 85 Hospital without finding a single negative review. All were fulsome in praise for the 85 Hospital. However, from the 8th page onwards it was continual negative reviews of the hospital by users. This is an example of Baidu having its search results  customer weighted. Interestingly, the 'promoted' 85 Hospital has 3000 reviews saying that it is a '5 Star" institution, whereas the non-promoted Fudan University hospital has only 51 reviews.

Baidu says its star rating system is automated and resistant to human manipulation. However, one internet rating and review 'specialist' said fake reviews were offered for 1.1 yuan per review. Another internet services company contacted by the reporter said they had offered similar review 'paid review. services to other private clinics. They said they could offer website setup and hosting quite cheaply, but Baidu search result manipulation would cost a lot more. He said the price for setting up a  search manipulation service would be about 90,000 yuan a month for top health sites such as hospitals. His financial model was to start with a monthly spend of about 50,000 yuan, which would get a 1:1 return, increasing over a year to about80-90,000 yuan a month, with a return of 1:3.5 on investment for a hospital.

All this may be about to change after the now famous spat between Putian and Baidu over 'compensated search' advertising for Putian network clinics. Putian clinics said that they were halting all advertising in protest at being overcharged by Baidu, but the search engine said it was cleaning up its search results to eliminate unauthorised health clinic advertising. Nevertheless, when IT News tried entering search terms synonymous with Putian clinics such as  "men's illness" [STDs], "Fertility Clinic" and "Gynaecology Clinic" all the top results were still for private clinics of the Putian chain. It seems the advertising boycott proclaimed for 1 April has yet to start in reality.

In 2013 the party secretary for Putian city said the healthcare companies based in the city spent 1.3 billion  on internet advertising for their national chains of clinics and hospitals, which represented about half of Baidu's revenue. They also represented the biggest source of patients to the clinics. According to Baidu, its  revenue from online advertising and paid search was 3.2 billion yuan, of which healthcare was just one five main areas that contributed to 54% of revenue.  In 2014 Baidu CFO Li Xinzhe said he expected healthcare to be one of the top contributors to revenue. This year so far Baidu has increased its revenue by 34% on the previous year. Draw your own conclusions.

Tuesday, 16 June 2015

Self circumcision attempt goes horribly wrong for Zhejiang man

by MICHAEL WOODHEAD
After working as a urological surgeon for five years at Zhejiang's Yongkang No1 People's Hospital, Dr Hu Xiang thought he'd seen it all. But near midnight on the 11th of June, a delicate-looking young man waddled into the department clutching at his groin. When Dr Hu asked what was the matter, the man removed his hands to reveal his trousers were stained with blood. After getting him to lie down on the bed, the man revealed that he had circumcised himself at home, and his penis foreskin would not stop bleeding. 

"Have you had medical training?" asked Dr Hu. The young man shook his head and said he had heard that circumcision was a simple operation and thought he would do the it himself. He had looked up how to do it in books and on the internet and had made an attempt when the rest of his family were out of the house.

When Dr Hu inspected the man's penis, he observed that it had been unevenly cut and what remained of foreskin was 'mashed' and was bleeding from areas where small blood vessel had been severed. The man had also tried to stitch up the cut penis with eight stitches of white sewing cotton.

Dr Hu asked him what had happened. The man said he was 30 years old, married with a daughter, and did not like the appearance of his foreskin, and thought it 'too long'. He had therefore gathered some scissors and some sewing needles and cotton and attempted to circumcise himself. When the scissors proved too blunt, he had tried a razor blade instead and was able to cut the foreskin. The man then sewed eight or nine stitches in the wound. None of the cutting and sewing implements had been sterilised, he admitted. Dr Hu noted that the man had cut too much and had damaged some of the erectile tissue of the penis in his amateur attempts at self-surgery.

The doctors in the urology department took the man in for surgery, to try curb the bleeding and prevent further complications. They did this under local anaesthetic, but were amazed to find the man kept sitting up and giving them advice on how they should do the operation. "Don't make any creases here .. make that bit look a bit more beautiful ..." he told them.

Dr Hu told local reporters that he was experienced in performing circumcisions, and these usually took no more than 20 minutes without complications. However, the self-circumciser had needed about an hour of surgery, including restorative plastic surgery to avoid disfigurement. The man had also warned them haughtily not to tell anyone about what had happened and not to talk to other members of staff at the hospital.

To add insult to injury, the patient then 'did a runner' after being left in the hospital ward to recover overnight. The next morning he had left without leaving any contact details. Dr Hu said the usual cost of circumcision was about 500 yuan, but this man had left an unpaid medical bill of 1000 yuan. He advised the man that he would have to return for follow up of his operation. If not, he could face serious complications such as infections and disfigurement.

Dr Hu's advice was that all circumcisions should be done in a proper hospital environment. he said he sometime had seen men who had circumcisions done in unofficial 'backstreet' clinics that did not have sterile equipment - and this could lead to excessive bleeding and skin  infections. However, he said this case was the first time he had seen someone try perform a circumcision on themself.

Sunday, 14 June 2015

Mobile healthcare in China: all you need to know

by MICHAEL WOODHEAD
I've written a great deal about the bottlenecks in the Chinese healthcare system and the problems that stem from having a hospital-based initial consultation system as opposed to European-style general practitioner gatekeepers. While China is slowing moving towards community clinics (most notably in Shanghai) - it will be a while before there is any system that efficiently triages and treats the minor illnesses and also provides continuity for people with chronic disease. 
In the meantime, Chinese patients are struggling to access doctors hidden away in the fortresses that are State-Owned Enterprise hospitals. They face a lot of hassle to register for an appointment and then long waits to actually see a doctor in a rushed consultation. Nobody is happy with this situation.

Enter the Mobile Healthcare providers (Cellphone for the Yanks). The Big Three at the moment are Baidu, Chunyu (Spring Rain) and Tencent-DXY. Let's deal with them one at a time.

Baidu are making big moves into mobile healthcare. They are China's biggest internet search engine and major internet player, so they have a lot of clout. Baidu are playing to their strength and basically offering an online appointments service, based on their search engine results.
The recently launched Baidu Doctor app allows users to find the nearest available doctors and book an appointment. It also includes some menus that allow the user to work out which kind of doctor they need to see. There is also a rating system that allows users to leave feedback on the quality of their experience. Baidu are rolling this service out nationally, province by province, and have made some strategic partnerships with key hospitals to ensure that they are offering appointments with certified, named doctors. So far they have signed up 1000 doctors nationally - not many in a country that has 3 million - but they are working to ensure that the doctors they enrol are kosher.
As a search engine, Baidu have had a bad reputation for advertising dodgy healthcare services, hence the recent falling out with the Putian chain of private clinics - who some have said owe more to marketing than medicine. Baidu are now trying to build up a reputation for quality and reliability - as well as convenience, and they certainly have the resources to invest in building up a network of doctors. However, by offering what is essentially an online referral system they seem to me to be duplicating the role of the general practitioner gatekeeper. How Baidu will sit with the government's policy of building up primary care and discouraging people from heading straight to hospital remains to be seen.

The next big name in mobile health is Chunyu - Spring Rain. They are essentially an online consultation provider - with an app turning the mobile phone into a telehealth device to allow the patient to speak directly to a doctor.  
www.chunyuyisheng.com claim to have 45,000 doctors online, and say they can hook up a patient with a doctor for a phone consult in just three minutes. The doctor provides advice and medical information in conjunction with Chunyu's online searchable medical library. The service also offers an electronic health record, personalised advice and links to nearby medical providers and pharmacies.

This seemed to be a promising avenue until the health ministry outlawed online consultations earlier this year except for patients registered with authorised hospitals. I'm not sure how Chunyu are managing their way round this, but they now say that users must be registered to receive medical consultations. They have also announced that Chunyu will be setting up bricks and mortar clinics in addition to their 'virtual' ones.
I personally am not a great believer in online consults. They may be useful as a convenient substitute for a limited number of consultations where the interaction between doctor and patient can be verbal - but most illnesses need a healthcare provider to be there to assess the patient in person. It is often the subtle signs that are only visible in the flesh so to speak that are the most crucial. Not to mention things like continuity of care, need for tests and scans and physical examination. When online doctors can remove earwax, change dressings and do Pap smears I'll get the app. Until then, it's just a glorified advice line.

Last but not least in the Mobile Health wave of the future is the partnership between Tencent and the doctors' forum site DXY.com (Ding Xiang Yuan - which translates as Lilac Garden).
I have a lot of respect for DXY.com because their forums are docgor-driven and the site for good quality doctor-to-doctor discussions. They also provide Continuing Medical Education (CME) and healthcare news. There's nothing really like DXY in the west. There are the so-called 'Facebook for Doctor' sites such as Sermo and Doc2Doc but they haven't really taken off and become universal in the way DXY has in China. I should point out that DXY is focused on younger doctors, though it does have content sourced from the older 'master clincians'. The success of DXY really reflects the positive attitude towards technology and social media among young Chinese - but sadly I think it also reflects the 'silo' mentality of Chinese healthcare and culture, cut off from the outside world. DXY features a lot of content and discussion around translated medical research from the west - the big journals such as JAMA for example. However, Chinese doctors seem to feel more comfortable discussing medical practice and developments in their native language and behind the Great Wall of DXY rather than venturing out into the wider online world and conversing directly in English. The lack of access to social media sites such as Twitter and Facebook means that most young Chinese clinicians can't take part in the many vibrant medical exchanges now going on in the social media sphere - groups such as Free Open Access medical Education (FOAMed), for example.

Anyway, Tencent has recently partnered with DXY, presumably hoping to harness all that young medical know-how and try to extend the online physician-to-physician communication links to physician-to-patient links. At a recent medical tech meeting, Tencent's investment manager Mu Yifei explained their philosophy in mobile health. Rather than being a 'disrupter' he said Tencent recognised that doctors would still be a the centre of any new online health system, and the company aimed to provide a new, smoother pathway between patients and doctors, based on data and information. Ma said that it was early days in mobile healthcare development, but they hoped to harness the skills of doctor online using the tools that have already brought them so much success in areas such as microblogging (Weibo), instant messaging (QQ) and their taxi app Didi (just banned). It's worth remembering that Tencent is a $200 billion company so they're not short of resources to invest in the mobile medical market.
Ma said the main areas for reform in medicine are unreliable costs, information silos, inefficiency in getting to see a doctor and the lack of good networks  for users of the healthcare system. He gave an example of how mobile networks for restaurants now allow users to find a restaurant, peruse the menu, order online, make a reservation then pay and leave feedback. Can this apply to healthcare too?

At present the DXY partnership offers only limited advice online for patients. The founder of DXY, cancer immunologist Dr Li Tiantian, is sceptical of the 'flashy' medical advice apps that are now in fashion. He has said  the future lies in two-way communication between patient and doctor, not one-way 'advice' from the physician. His vision is for patients to be given more encouragement to self manage their illness and give feedback to the healthcare provider. In this, he sees the longer term role of DXY in collecting and using information from patients - rather like a market research company - instead of just pushing out information and services to patients.

This then, is my brief introduction to the mobile health players in China. It's a fast moving field, and like other areas of internet and social media in China, it is very much a local game, with western companies either excluded or late to the game. Having said that, China seems to be leading the way in mobile health - there is great enthusiasm for mobile solutions and the Chinese are avid early adopters. China also faces less of the red tape and regulatory barriers that exist in the west around matters such as patient privacy, confidentiality of data and the regulations around doctors' scope of practice when offering online consultations. The other big barrier to online health in the west is remuneration - doctors are highly paid and beholden to either medical insurers (the US) or national payers (NHS, Medicare) for their income. With huge pressure on their already mushrooming budgets healthcare payers are loathe to open up new channels in which doctors could claim income and further inflate costs.
In China, things are different. Doctors are poorly paid and at the mercy of their  State-Owned Enterprise hospital managers. The government is actively working to break these shackles and encouraging doctors to work independently in private practice. If China's doctors can see an income stream from mobile health, they may well jump in and meet the apparent huge demand for their services. The players in mobile health say that China's healthcare market will be worth trillions of yuan in 2020 - and much of that will be online.

Sunday, 7 June 2015

China's government take the biggest step towards private healthcare

by MICHAEL WOODHEAD

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

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

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

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

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

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

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

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

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

My top ten China healthcare stories for the week


1. Chinese people's cholesterol levels are going through the roof. The mean daily cholesterol intake in Chinese adults increased from 166 mg/day in 1991 to 266 mg/day in 2011, with eggs, pork, fish and shellfish most to blame - although cholesterol intake from chicken is also considerable.

2. The number of Chinese people diagnosed with schizophrenia has increased from 3 million in 1990 to 7.2 million in 2010, a 132% increase, say researchers from Beijing. They say the incerase is far ahead of population growth and is linked to increasing urbanisation.

3. Schistosomiasis has been resurging in certain areas of China where its transmission was previously well controlled or interrupted, possibly due to a more mobile population re-introducing the parasite, say Suzhou researchers.

4. Exposure to pesticides is casing serious health risks to China's rural dwellers, a study of 246 farmers from Guangdong, Jiangxi, and Hebei has found. Pesticide exposure was high and those exposed showed adverse effects on nerve function, blood cell levels and liver function.

Good news on infant mortality rates: in Zhejiang they have fallen more than 60% since 1997, from 7.85 to 2.81 per 1000 livebirths for neonates.

5. China's hospital rarely recommend TCM. While China has many hospitals dedicated to Chinese Traditional Medicine, the majority focus on western medicine, and few of them recommend TCM in their clinical guidelines. A review of more than 600 clinical practice guidelines found that only 12% recommended TCM therapy.

6. Don't eat those wild mushrooms: heavy metal pollution in wild edible mushrooms is a serious problem in the Yunnan Province, a new stud shows. Analysis of wild mushrooms found that they contained hazardous levels of arsenic and cadmium.

7. Heavy metal contamination is also a problem for rice supplies in some parts of China. A study of five areas of China found that about 20% of rice samples exceeded the maximum allowable cadmium levels, with some areas of Guizhou having 40% of rice with serious contamination.

8. Dengue fever is an emerging problem in China that demands attention, according to doctors from Viral Disease and Vaccine Translational Research Unit, Institut Pasteur of Shanghai. They say the disease has come from nowhere to epidemic proportions, with 1000 cases discovered each week in Guangdong since September 2014. They blame increased overseas travel by Chinese and returning travellers.

9. Another emerging infectious disease of concern is the tick-borne disease Babesiosis, which has been reported for the first time in two patients near the Burma border in Yunnan.

10. Tibetans have a high risk of cardiovascular disease, with a high rate of risk factors such as hypertension seen in the more prosperous, lamas and those living at lower altitudes.The findings suggest that without the immediate implementation of an efficient policy to control these risk factors, cardiovascular disease will eventually become a major disease burden among Tibetans, say researchers from Tibet and Tianjin.

Sunday, 31 May 2015

China healthcare headlines - June 2015

Beijing to ban smoking in public place 

Smoking will be banned in public areas of Beijing such as restaurants, offices and on public transport from 1 June, but enforcement is in doubt. According to the new anti-smoking rules, smokers will face
fines of 200 yuan ($32.25) for smoking near hospitals and schools, while business can be fined up to 10,000 yuan ($1,600) for failing to enforce no-smoking areas.

Doctor killer executed

The man who stabbed a doctor to death at a Wenling hospital in a dispute over  surgery outcomes has been executed in Zhejiang. The man called Lian Enqing murdered an ENT specialist in October 2014 because he was upset about the poor results of surgery on his nose.

Air pollution triggers hospital admissions

Hospital admissions for respiratory problems increase dramatically when air pollution PM2.5 particle levels exceed a threshold of 200 µg/m3 according to researchers from Shandong.
Lian Enqing was sentenced to death last year for a fatal attack on an an ear, nose and throat specialist in Wenling, in the eastern province of Zhejiang. He attacked the doctor because he "felt displeased with his nose and claimed to be suffering respiratory problems", the official news agency Xinhua said - See more at: http://www.straitstimes.com/news/asia/east-asia/story/china-executes-patient-who-stabbed-doctor-death-over-nose-operation-report#sthash.mIPzSQ7W.dpuf
Lian Enqing was sentenced to death last year for a fatal attack on an an ear, nose and throat specialist in Wenling, in the eastern province of Zhejiang. He attacked the doctor because he "felt displeased with his nose and claimed to be suffering respiratory problems", the official news agency Xinhua said - See more at: http://www.straitstimes.com/news/asia/east-asia/story/china-executes-patient-who-stabbed-doctor-death-over-nose-operation-report#sthash.mIPzSQ7W.dpuf

Private hospitals blocked by public hospital chief

Despite being encouraged by central, the development of private hospitals is being blocked by the all powerful managers of major public hospitals, according to an article in Caixin. Analysts say that public hospitals are effectively operating as for-profit monopoly providers and they are loathe to give up their staff or patients to private newcomers.

Health minister's book published by Elsevier

Former health minister Chen Zhu is having a book publichsed by international medical publisher Elsevier. The book entitled Healthy China 2020: Strategic Research Report, is an in-depth review of China's past present and futre healthcare developments, with contributions frm many leading healthcare figures.

China's hospital league tables published

A league table of China's best hospitals, ranked by department, has been published by the China National Medical Information Center. The ranking tables put hospitals in the three major cities of Beijing, Shanghai and Guangzhou at the top of most lists, according to criteria for 19 different specialities.

Sunday, 24 May 2015

Multidrug resistant leprosy, Tuberculosis costs; Clinical trial problems; Milk formula mispercetions, Rheumatoid arthritis drug unavailable

Doctors in Shandong have reported China's first cases of multidrug resistant leprosy. Testing 85 samples of the causative bacteria Mycobacterium leprae, doctors found that some were resistant to  standard antibiotic treatments including dapsone, rifampin and ofloxacin.

In theory, tuberculosis treatment is free in China, but in reality patients  still face enormous out-of-pocket costs for treatment, a study from Jiangsu show. In a survey of treatment costs for people in the province, researchers from Nanjing Medical University found that the average cost per patient was as high as 19,000 yuan (US$3000). Even for patients who could claim back medical costs on their health insurance, out of pocket costs were still around 14,000 yuan ($2260) a year for clinic visits, hospital stays, tests and drug therapy.

Clinical trials are difficult to set up and run in China due to a lack of qualified and experienced clinical research staff and poor research infrastructure, an experts says. Dr Wu Yangfeng Wu of the Peking University Clinical Research Institute (PUCRI) said clinical trials required a pool of many hundreds of clinicians who were educated and well versed in basic research techniques - something which China lacked. He told Forbes that China's medical institutions also lacked  basic infrastructure and research management systems to conduct trials. There were also few allowances or rewards for doctors who took part in research, he added.

As many as one in five village doctors have latent tuberculosis, according to a study carried out in the Chinese province of Inner Mongolia. Dr He Guangxue and colleagues at the Chinese Center for Disease Control and Prevention, Beijing, surveyed 880 village doctors and found that 19.5% had positive tuberculin skin reactions. Latent tuberculosis risk was highest in doctors who had been in practice for a long time and for doctors who had more exposure to patients, they showed in PLOS One.

About 90% of Chinese mothers opt for milk formula within a month of giving birth, often driven by misguided beliefs and fears, a study from Sichuan has found. In a survey of 695 new mothers, 88% had initiated formula within 4 weeks of giving birth, often believing that babies slept better after fed with formula, and many believing they had insufficient breastmilk.

One of the best drug treatments for rheumatoid arthritis is out of reach for many Chinese patients because of cost, rheumatologists say. Chinese clinical experience with tocilizumab (Actemra) showed that it was highly effective and safe.  However, the high cost of the drug limits its prescribing in China, according to Dr Wang Geng of the Department of Rheumatology and Immunology, Changzheng Hospital, The Second Military Medical University, Shanghai.

Insurance fraud: how three doctors placed the bodies of dead cancer patients in staged traffic accidents to swindle $225,000

by Michael Woodhead
In a sophisticated and ghoulish scam, three doctors at an Anhui hospital used the bodies of recently deceased cancer patients in staged traffic accident in order to claim thousands of dollars in insurance payouts.
The doctors who worked in the intensive care unit of Lingbi Hospital were part of a gang of seven, including former insurance company employees, who used the bodies of cancer patients to swindle insurance companies out of 1.4 million yuan ($225,000) in payments for 42 fraudulent claims.
The doctors used their contacts to identify terminally ill cancer patients, who they would then arrange to have insurance policies for accidental death taken out. After they died, the doctors did not carry out the usual death certificates, but instead shipped the bodies to locations where they set up traffic accidents, often involving motorbikes or scooters. When police and emergency services arrived on the scene they would declare the victim dead due to a traffic accident, and the insurance companies would pay out on their policies.
However, authorities became suspicious when a large number of traffic accident claims were made in a short period. When they set up an investigation, they found the same three doctors - and their relatives - were involved in all the claims.
The doctors have now been arrested for insurance fraud and suspended from their positions at the Anhui Lingbi hospital.

Monday, 18 May 2015

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


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

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

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

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

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

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

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

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

Source: WHO Bulletin

Sunday, 17 May 2015

Drug sale reforms; Autistic children abused; Tibetan monks don't get hypertension; Guangzhou's first private clinic; Doctors stabbed in Fuzhou; Tax breaks for private health insurance


by MICHAEL WOODHEAD
The move to stop county-level hospitals from deriving their income from 15% markups on pharmaceuticals will severely dent their revenue stream and threaten services, health economists have warned. China has already trialled  drug commission bans in 300 county hospitals and now plans to extend the system to 1000 hospitals nationally, Caixin reports. However, the plan could leave hospitals short of funds and thus reduce the level of services and hurt the morale of medical workers,  academics and doctors say. The State Council has said local governments should help hospitals to make up for the lost income from drug sales. However,Wang Zhen, a research fellow at the Chinese Academy of Social Sciences, said local governments were already strained financially and they don't have extra money for hospitals.Wang said that without government subsidies and other measures in place, scrapping the markup practice might wind up creating other problems because hospitals will find alternative ways to make money.

Children with autism in China face experience high rates of physical abuse from their parents and family members, a study from Henan shows. In a survey of 180 children with autism, Zhengzhou researchers found that 36% had recently experienced severe physical maltreatment such as slapping on the face, being beaten with objects or kicked. Less severe physical maltreatment such as being slapped, or shaken was experienced by 86% of autistic children.

Tibetan monks have low rates of hypertension, according to a study carried out in Gansu. The survey of 984 monks found that 19% had hypertension, compared to 34% of the local population. However, despite having low rates of high blood pressure, there were also low rates of awareness, treatment and control of hypertension among monks, the researchers found.

Encouraged by new government policy a surgical oncologist has opened Guangzhou's first major private clinic. The clinic set up by Dr Lin Feng will offer speedy diagnosis and high quality treatment by a well known surgeon previously practicing at the renowned 3rd Hospital of Guangzhou. The clinic charges about 2-3000 yuan fees, and offers high quality diagnosis and surgery without the long waits and rushed consultations of public hospitals, its operators say.

Two doctors at a Fuzhou hospital were stabbed in an attack by a 66-year old male patient, local media report. One male and one female doctor were seriously injured by the man armed with a 40cm knife who had been attending the Fuzhou hospital to have his haemorrhoids treated. A hospital spokesman said the man was unhappy with the treatment he received for his haemorrhoids and stabbed a female doctor in the hip. The male doctor who tried to restrain him was also stabbed in the arm.

Tax breaks are to be introduced for Chinese consumers who take out private health insurance, the government has announced. People who spend more than 2,400 yuan on commercial health insurance policies per year will now only pay individual taxes on income above 3,700 yuan per month, instead of 3,500 yuan, CCTV has reported. The move is part of a government campaign to encourage Chinese people to  purchase private health policies in addition to their standard government benefits.

Thursday, 14 May 2015

Personal experience of the Chinese health system

An overseas Chinese friend of mine has just come back from China, where she returned to care for her dying father. Her experience of the Chinese health system was mostly positive, but her story reveals some of the reality behind the rhetoric of recent government pronouncements on reforms.
Her father was seriously ill with lung cancer and had only a few weeks to live. After the diagnosis, at an army-affiliated hospital, the doctors did not try to offer futile chemotherapy with expensive drugs, but just offered a poor but honest prognosis. There was no access to what we in the west would call palliative care. Instead, doctors recommended that he return home, to be cared for by family members. In some pain and discomfort, the father was provided with some analgesics, but no opioids.

After about a week, the father was in considerable pain and returned to the hospital for treatment. He lived for another 18 days, being given a mixture of analgesics and other drugs to ease his bowel problems. The cost of treatment was 18,000 yuan. As he had been a member of his employer's urban health insurance plan, the father (or rather his family) was able to claim back about 70% of the medical expenses. However, the hospital treatment did not include 'extras' such as meals, dressings and bed linen! The nurses provided most of the basic medical care but none of the ancillary care such as washing, feeding and chaging bed linen that nurses in western hospitals would do. Instead this was left to the family. As the family were not able to be on 24/7 carer duty they hired a 'kanghu' carer at a cost of 800 yuan per day, to do basic chores such as feeding and cleaning the patient.

The family were satisfied with the overall level of medical care provided by the hospital, though they found it somewhat basic until they used their guanxi to find a better team of doctors and nurses. This was done because they knew someone who knew one of the senior doctors at the hospital.No money changed hands, but the father benefited form having more attention paid to his care by the more senior medical practitioner in the hospitals. After the father passed away, the family presented hongbao containing about 200 yuan to each of the 20 medical team who cared for him. This was done to maintain face and  confirm the good guangxi that was used to obtain better care for the father.
Funeral arrangements were made for the father via the hospital contacts, who no doubt gained some financial advantage from their referral.

The family believed their father received good care that was personal and respectful - but no doubt because they were able to use their connections in what was essentially a small city where everybody knew everybody.

Monday, 4 May 2015

Hypertension treatment outdated; Infants hit by Group B Streptococcal infections; Liver disease brings ruinously medical bills; Caesarean sections the norm; Li Keqiang unhappy with pace of health reforms

by MICHAEL WOODHEAD
Treatment of high blood pressure in China is quite backward because it is exactly that - treatment of just the raised blood pressure, with no attention to other cardiovascular risk factors. Cardiologists now emphasise that it is essential to treat a person's overall cardiovascular risk, not just focus on single risk factors such as blood pressure. But a study carried out in 274 hypertensive patients in Zhejiang found that  found that 28% were still smoking, 39% drank regularly and only 21% exercised frequently. The average salt intake per day was above the national recommended level of 6g. The study also found that most patients were taking only one drug for high blood pressure, which was inadequate to control their blood pressure. Many were taking 'herbal' medicines that actually contained out of date and dangerous western antihypertensives such as reserpine. As the authors conclude: "The study revealed outdated and inadequate treatment and health education for hypertensive patients, especially for those who have high risk scores for CVD. There is a need to review the community-based guidelines for hypertension management."

In Shenzhen, researchers at the Children's Hospital have shown that invasive group B streptococcal infection is an important pathogen in infants under 90 days old, resulting in in high mortality and neurological sequelae. The streptococcal infection strains showed strong resistance to clindamycin and erythromycin.

Liver disease is an expensive condition that often sees families facing ruinous medical bills in China. A study carried out at a Kunming hospital found that the average yearly cost of medical treatment for hepatitis B was 19,496 RMB, while patients with cirrhosis faced bills of up to 46,061 RMB. While public medical insurance helped pay for some of the costs, catastrophic health expenditure occurred for families affected by all these illnesses.

China's high rate of caesarean sections will be difficult to bring down to more healthy levels, according to researchers. In a  survey of a112,138 women they found the cesarean delivery rate was 55% and as high as 66% in some regions. Two thirds of the cesarean deliveries were scheduled and performed before labour  and about 40%%  were performed without any recognised medical indications. About 57% of the caesareans were done on request of the mother.

Meanwhile, the progress of health reform is obviously too slow for the Premier Li Keqiang. This month he has called for more medical reform measures to overcome 'difficulties' in the healthcare system. In written instructions he identified problems areas that needed attention, such as hospitals should be prevented from being "financed by drug sales" He also said that more effort should be given to reform of county-level hospitals and more serious diseases needed to be covered by medical insurance. His orders came after reform measures were introduced across all county-level hospitals and are now being piloted in 100 city-level hospitals.

Sunday, 26 April 2015

Rural doctors in China; Free cancer screening; New TB vaccine; Do doctors have good cardiac skills?

by MICHAEL WOODHEAD

In a sign of the increasing concern about the demise of rural healthcare, China's 1.4 million rural doctors have now been given their own professional organisation.
Although it's not quite a trade union, the Chinese Medical Association has established a rural doctors section that will represent the interests of the many village doctors. The move is in response to the ageing of the semi-skilled workforce, most of whom lack medical degrees and have only high school education and a short training course on healthcare provision. According to the CMA, the new Rural Doctors Association "will assist the government to strengthen and promote rural doctor team building for the survival and development of rural medicine and safeguard the legitimate rights and interests of rural doctors."
Earlier this year Premier Li Keqiang acknowledged that it was important to retain doctors in rural areas, because their primary care role was "more effective than building a large hospital." The State Council acknowledged that rural doctors were the cornerstone of primary healthcare for hundreds of millions of rural residents.
However, most rural doctors are approaching retirement and younger people do not want to work in remote 'backward' areas in a role that is poorly paid and has few career prospects. Rural doctors by decree are paid the same salary as rural teachers - which is a pittance.Their miniscule pensions are an even greater cause for complaint.

Free screening programs for breast cancer and cervical cancer are to be developed nationally in China, according to the National Health and Family Planning Commission. The ministry said 48 million women in rural China had already received cancer screening interventions since 2009,  and there were now plans to increase promotion of screening services, co-ordinated by the All-China Women's Federation.

Despite studying medicine for seven years, China's junior doctors are unable to manage the basics of dealing with a heart attack, a study shows. A survey of 362 new medical graduates found they had little knowledge about basic cardiac diagnosis and resuscitation. Only about 50% of the doctors were able to identify common normal and abnormal ECG changes such as ventricular fibrillation. Likewise only half knew the basics of which drugs should be given for such conditions. The findings showed that many medical graduates were unprepared to manage the most common cardiac emergencies said researcher Dr Xi Huijun and colleagues from the Changhai Hospital, Shanghai.

China is leading the world in developing a new TB vaccine to replace the largely ineffective BCG vaccine against tuberculosis. At a TB vaccine conference held in Shanghai, researchers heard that a vaccine called Vaccae developed by an Anhui pharmaceutical company is in Phase 3 trials, whereas other candidate vaccines from other countries are only in the preliminary stages. Researchers said the vaccine would probably of most use in the elderly, who are expected to account for more than half of tuberculosis cases in the future.

Monday, 20 April 2015

Are Chinese hospitals safe? Fear of blame and shame is common, but the overall safety climate is good

by MICHAEL WOODHEAD

China may not have as many ambulance-chasing lawyers as the US, but healthcare staff live in fear of making mistakes because of a culture of blame and shame. Not so much "Better Call Saul" as "Better Keep Quiet".

While in the west there is now an attempt to make healthcare staff be more open and transparent in reporting medical mistakes, it seems like China has a long way to go in overcoming cultural barriers to admitting to errors. In a survey of 1272 healthcare staff at Shanghai hospitals, researchers found that there was a high level of fear of being blamed and fear of being subject to shame. Almost three quarters of staff said they would be disciplined if found making a mistake and 42% thought that asking for help was a sign of incompetence. A similar proportion of staff - 42% - thought that telling others about mistakes was embarrassing, and 40% of thought that it was better to not report errors in the hope that nobody would notice the mistake.

Worryingly, work pressure was also a major factor in mistakes - and covering them up - with about 60% of staff saying that with higher workloads, management forced them to work faster and taking shortcuts that might negatively affect patient safety. About 40% of hospital staff said they had witnessed a coworker do something that appeared to be unsafe in patient care in the last year and one in three staff admitted they had done something that was unsafe for patient car.

The fear of blame and shame phenomenon appears to be an Asian and Chinese concept. The 40-70% levels of 'blame and shame' fears seen in the study were much higher than the 5% rates seen in U.S. hospitals. As the authors note:

"Chinese society tends to be more collective than the Western society, which is called “familial collectivism” People admitting mistakes do not only embarrass themselves but also embarrass the team. Thus, [healthcare] workers may be reluctant to admit to making mistakes in China."

Interestingly, doctors had the highest levels of  “fear of shame” and the researchers said this chimed with the finding that Chinese doctors do not believe that “human error is inevitable”,  - in other words, Chinese doctors feel they must act like gods and be seen to be infallible - whereas admitting a mistake would be a sign of incompetence. This is consistent with “fear of shame” being particularly high among physicians. The Confucian ethic was also seen in the high levels of fear about reporting mistakes made by more senior staff that endanger patient safety.

Nevertheless, the overall safety climate in hospitals was no worse than that seen in the US, with 15% of staff giving 'problematic' responses to safety questions. As the authors said, Chinese healthcare workers are only likely to report mistakes and safety issue when they feel psychologically safe and do not have to fear being blamed and shamed.

The findings are published in BioMed Central.