Wednesday, 17 September 2014

Medical comic strips | Anti-smoking laws weakened | No support for Orphan Diseases

A female doctor in Shanghai draws weekly comic strips and posts them on WeChat to try demystify medical jargon and improve doctor-patient relations
Dr Chen Haiyan, a cardiac ultrasonographer at the Shanghai Zhongshan Hospital has used the comic strips to explain conditions such as heart defects and high blood pressure in easy-to-understand ways. She also tries to explain the daily life of medical staff and show they are human in an effort to defuse the major tensions that have triggered many recent violent attacks against hospital staff.

Health experts have expressed disappointment that Beijing's proposed anti-smoking regulations have been watered down. The latest draft legislation only bans smoking in "shared indoor public places," compared to a previous draft that banned smoking in all indoor public areas, said Professor
Wang Qingbin, a legal expert at the China University of Political Science and Law,
"By banning smoking only in 'shared' indoor public areas, the legislators are giving officials with their own offices a chance to smoke, which is against the spirit of equality," Wang said, adding that it will only make law enforcement all the more difficult.

China lacks adequate health systems to deal with rare 'orphan' diseases such as Duchenne Muscular Dystrophy, medical experts say. At a recent conference on rare diseases at the Children's Hospital of Fudan University experts called for legislation and policies on the prevention and treatment of rare diseases that affect more than 10 million people in China."Related regulations should be created to help provide better support to patients with rare diseases and their families," said Li Dingguo, chairman of the rare disease branch of the Shanghai Medical Association.

Sunday, 14 September 2014

Intern scheme concerns | Telehealth ban sparks backlash | Rural residents too poor to pay for care

Internship scheme will create bottlenecks and headaches
Doctor training moves to a three-year internship system next year but many medics believe the changes will leave hospitals with even worse staffing shortages. The new system which will see newly-graduated doctors rotate through various hospital departments to gain experience is intended to bring China into line with other countries and to create a uniform high standard of medical practitioners. However, critics warn that the additional three years of being a trainee will mean that doctors earn very little and the low income will deter many from entering the medical profession. Another drawback of the new system is that doctors will serve as interns in tertiary 'teaching hospitals' and will then refuse to be 'downgraded' to work in smaller local country and township hospitals.

Ban on telehealth consultations triggers backlash
There has been a major backlash against an announcement that doctors will be banned from conducting online consultations by the National Health and Family Planning Commissioning. The NHFPC said this week that 'remote' consultations are illegal except through accredited medical institutions because all doctor consultations need to be carried out according to the regulations of the NHFPC as currently laid down for hospitals and clinics. The NHFPC said remote consultations should be viewed as no different to any other kind of consultation and therefore all the usual regulations on medical practice apply. However, after a major backlash from health groups and online health providers such as, the NHFPC said it would look again at the legislation and would 'listen to the opinion of the masses' in interpreting the legislation.

Rural health insurance not working
People who live in remote rural areas of China are so poor they cannot afford to seek medical attention when they are sick,  a study from Hebei has found. More than 50% of people living in the Dabie mountain areas of Hebei said they would not seek medical care if they felt unwell. The main reason (for 38% of people) was financial difficulty. Other reasons included inconvenience and preference to self medicate. Researcher Dr Fang Pengqian and colleagues from the Tongji Medical College, Wuhan said the findings suggested that the universal health coverage from the New Cooperative Medical Scheme (NCMS) was was not working for people in poorer highland areas. They said the locals could not afford to pay the necessary insurance premiums to  cover basic care and the low reimbursement meant they faced high out-of-pocket costs.

Friday, 12 September 2014

Doctors lose, retail pharmacies win as government cuts the hospital monopoly on dispensing

by Michael Woodhead
The Chinese government appears to have side-stepped the influential doctors' lobby and the tame health ministry by using the Ministry of Commerce to tackle the perennial problem of drug sales commissions and the inflated cost of medicines.

Doctors in China rely for much of their income on commissions and bonuses from sales of pharmaceuticals, and previous efforts to curtail the profits have been stymied by medical lobby groups. The Ministry of Health, previously led by a medic Dr Chen Zhu (who now heads the Chinese Medical Association), has managed to block or delay previous efforts to tackle the drug commissions problem.

Now the government has turned to the Ministry of Commerce to introduce new rules that separate medical services and drug sales in 34 pilot cities across the country, in an attempt to lower the high cost of medicines. The National Health and Family Planning Commission (which absorbed the Ministry of Health last year) has been sidelined by the move, a sign that its own efforts at reform have failed.

Under the new Ministry of Commerce plan, major city pharmacies will replace hospital pharmacies as the source of prescription drug dispensing, putting an end to the lucrative 'gold mine' of revenue for hospitals. In theory, this will mean that hospitals should no longer pressure their doctors to prescribe more and reach quotas to boost revenue via the hospital pharmacies. And by breaking the hospital pharmacy monopoly, the new plan will lower drug prices by encouraging competition between pharmacies.

According to Caixin, previous efforts to break the drug sales-hospital income link have failed because of entrenched opposition from the former Ministry of Health. The ministry pushed a plan under which local governments purchased pharmaceuticals on behalf of local hospitals, but this scheme was ineffective in breaking the stranglehold of hospitals on drug demand and also proved to be yet another channel for corruption.

 The new scheme will also permit more pharmacies to become eligible for reimbursement under the various medical insurance system. These moves will further increase diversity and competition and give pharmacies a boost in business, commentators say. However there has been no analysis of how public hospitals will make up for the huge gap in revenue when their lucrative pharmaceutical monopoly is snatched from them.

Wednesday, 10 September 2014

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

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

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

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

Tuesday, 9 September 2014

Medical accidents kill more people than traffic accidents

by Michael Woodhead
In China there are about 8 million unnatural deaths every years and of these about 400,000 are said to be due to medical accidents - often due to unsafe use of medicines. To try and remedy this poor situation, September has been nominated as national medication safety month by the China State Food and Drug Administration.

According to pharmacist Zhang Jichun of the Chinese Pharmaceutical Association, this high rate of accidents and adverse reactions with medications is due to widespread ignorance in the population about appropriate use of medical drugs. A recent survey of more than one million Chinese found that only about one in ten could answer correctly questions about basic drug safe use.

The higher error rate with drug misuse included allergic reactions to antibiotics in babies and infants, misuse of drugs by pregnant women causing birth defects and adverse birth outcomes, accidental drug overdoses, misuse of sleeping tablets causing accidents, using drugs past their shelf life, taking multiple drugs and causing interactions, abuse of weight loss drugs causing cardiac problems and deaths and failing to use cardiac drugs in sufficient doses leading to heart attacks and strokes.

The survey found that there were many problems with the way Chinese people used medications. About 90% bought prescription drugs from pharmacies and self-treated without getting advice or a diagnosis from a doctor. Almost 70% did not read the package insert and a third made major mistakes in dosing while 25% did not take the medicine correctly and failed o get the expected benefit.

 Zhang Jichun said many of the problems with drugs occurred in children and the elderly, who were more susceptible to their effects. A typical and common avoidable serious problem was deafness seen in 300,000 children due to overuse of some classes of antibiotics. This side effect occurred due to parental medication without being aware of the risks.

In the elderly one of the main problems was excessive medication, he added. Many elderly people take several different drugs for various ailments without understanding that they can interact to cause severe side effects, he said. Elderly people also made the mistake of taking western medicines with Chinese traditional medications, and this could also cause problems he said.

To try address this problem the China Pharmaceutical Association has set up a "medication safety expert advice hotline” and invites all Chinese to seek advice before using medications.

Sunday, 7 September 2014

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

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

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

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

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

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

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

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

Smoking cessation prospects poor | Bleak outlook for foreign-owned hospitals | 500 children die of rabies every year

Smoking cessation efforts are doomed to fail in rural China unless the culture of  giving cigarettes as gifts can be broken, say researchers from the Ministry of Health in Jinan, Shandong. Their study found that although many people in rural China attempted to quit at the advice of other family members, relapses were common and few were able to quit completely because they were culturally expected to share cigarettes. The study also found that village doctors did not smoking cessation advice to all patients and there were few if any smoking cessation programs in rural areas.

Allowing foreign companies to set up and operate hospitals in China will not make much difference to overstretched health services, a leading health official says in Caxin. Lian Xinbo says the real barriers are in employment and insurance regulations which mean that foreign companies will find it difficult to attract talented doctors and also to offer services that are reimbursed by health insurers.

More than 500 Chinese children die of rabies every year, and tragically most of the deaths could have been avoided if children had received correct treatment, say clinicians from the National Institute for Viral Disease Control and Prevention in Beijing. Most of the rabies cases occur in rural areas and are due to bites by domestic or stray dogs. However, few children with rabies get the recommended treatment of post-exposure rabies injections or even adequate wound care.

Thursday, 4 September 2014

Medical schools in China: outdated and unpopular

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

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

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

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

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

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

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

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

Will things improve in the near future? It's hard to see how, as huge class sizes are a barrier to more innovative teaching methods such as problem-based learning, and encouraging interaction and discussion.
China's medical schools may need to take a leaf from the book of China's factories. Instead of mass producing unpopular low quality products they could adapt the best foreign know-how and methods through joint ventures to produce a wider range of higher quality sought-after products.

Tuesday, 2 September 2014

Schistosomiasis eradication at snail's pace | Medical guinea pigs paid 10,000 yuan | DXY gets $70 million investment boost

Eradication of schistosomiasis in China is being hindered by factors such as lack of political and financial support, praziquantel resistance and climate change, say clinicians from the Jiangsu Institute of Parasitical Diseases in Wuxi. A sense of complacency has set in since the  prevalence of schistosomiasis was reduced to about 1% in animals and humans, they say. Renewed efforts are needed to ensure the final elimination of the parasite by 2020 and avoid its re-emergence, they say.

Young Chinese are signing up to be human guinea pigs in pharmaceutical drug tests and trials, being paid up to 10,000 yuan to be injected with experimental drugs. Medical students are the most popular choice for the first human trials of the 10,000 different trials run by China's 6,000 pharmaceutical firm.

China's leading medical social network site DXY has received $70 million in investment funding from Tencent, which will start to use the doctor networks as part of its services to consumers in the form of online consultations and appointment booking services. DXY will also develop new products in the healthcare area for consumers as well as doctors.

Monday, 1 September 2014

Chinese prefer foreign brands - especially when it comes to medical journals

One of the more provocative articles in the China-themed Lancet this week is a brief letter from two orthopaedic surgeons in Xian. 

Dr Yang Junsong and Dr Hao Dingjun complain about the quality of medical journals in China and how Chinese clinicians invariably prefer to be published in foreign medical journals. This is because of the publish-for-promotion phenomenon which I touched on last week - to gain promotion in a Chinese hospital, a doctor needs to acquire a list of published research, and the greater the Impact Factor of the journal the better.

As Drs Yang and Hao remark, there has been a tidal wave of medical journal articles published by Chinese clinicians in recent years, and yet medical publishing is in crisis. Why? Because most of it is crap. Scholarly articles are not being published to to be read or to further scientific knowledge, but to be listed and to obtain the magic piece of paper that counts towards career advancement.

Well, you might say, this sort of things happens to all academics and clinicians  and you'd be right. But the scale of the problem in China - and the sheer numbers involved - means this is distorting medical publishing and also drowning out the genuine research and academic discussion that deserves to be published but which struggles to reach the most suitable audience.

Another problem noted by the doctors from the Medical College of Xi'an Jiaotong University is that most doctors in China don't read English language journals. They may only have access to Chinese language journals and these are poor in quality because they being neglected by Chinese researchers - and they are also often profit seeking rather than having any sense of collegiality. As the authors note, Chinese doctors deal with 4 billion patient consults a year and they depend on Chinese medical journals as their main source of medical information - if this is rubbish, where can they get good quality research,  evidence and discussion from to inform their practice?

"Rebuilding a scientific and reasonable assessment system for medical research would be an essential step for the Chinese government," the authors conclude.

This isn't the first complaint about medical publishing in China. The Economist touched on the  problem of poor quality - and sometimes fake - medical research publications last year. Other bloggers have also highlighted the bizarre practice of bonuses paid to researchers in China in proportion to the impact factor of journals they get published in: $300 for a low impact journal, and the jackpot of $30,000 for getting a paper in Science or Nature! This reminds me of Chiang Kai Shek's system or rewarding his air force pilots with dollar bonuses for every enemy aeroplane they shot down.

I can only agree with this article by a frustrated academic: "We must stop the avalanche of low quality research..."

Sunday, 31 August 2014

China's move to promote private hospitals means health system will go from bad to worse: experts

In a scathing critique in the Lancet's special China-themed issue, health economists from Oxford and Harvard say that the Xi Jinping government's recent swing to favouring private sector involvement in the health system will be a retrograde step with 'dismal' consequences for health in China.

Professor Winnie Yip and Professor William Hsiao say the new target of giving private hospitals a 20% market share by 2015 is misguided and will promote wasteful and inequitable care. And most importantly, it will do little to improve China's already rotten public hospital system, which suffers from the worst of both words - state-controlled but with a user-pays private model of financing.

Their conclusion is that if the private hospital system continues: "population health outcomes would suffer; health-care expenditures would escalate, with patients bearing increasing costs; and a two-tiered system would emerge in which access and quality of care are decided by ability to pay."

They say China made a good start to health reform with the landmark 2009 decision to introduce universal and affordable public health insurance cover for both rural and urban residents. However they warn that the limited improvements achieved so far will be negated if the privatisation of an already profit-driven public hospital sector goes ahead.

The article is worth reading for its detailed dissection of the ills of the current hospital system, in which state-owned institutions are driven to maximise revenue by overservicing on unnecessary prescribing, tests and procedures. This sentence sums it up:

"Because physician staff are the residual claimants of profits in public hospitals, they are de facto shareholders of the public hospitals. Hence, public hospitals have neither the motivation nor the incentive to integrate care with primary health-care providers or make treatment decisions based on cost-effectiveness or population health maximisation criteria."

They warn that adding private hospitals into this already toxic situation will create even more problems as state-owned for-profit hospitals enter a "medical arms race" with private hospitals to provide more services at higher cost to patients - especially as private hospitals are already being planned by pharma companies and medical device companies.

"Overall, our assessment suggests that China's prospect of provision of affordable and equitable access to health care with a primary health-care-centred integrated delivery model approach would be relatively dismal. The for-profit motive of large public hospitals would result in escalation of health-care cost, inefficient use of pharmaceutical and high-tech diagnostic tests, and an absence of incentives for public hospitals to integrate care with primary health-care facilities. Entrance of private investment will further exacerbate these trends."

The Lancet devotes an issue to China

The Lancet this week has China has its theme, and includes many interesting articles on a wide range of topics around medicine and health in China. 

There's a huge amount of material there and I don't really know where to start in reporting it all. The articles cover everything from China's medical education system, the challenge of non-communicable diseases and even a couple of clinical research articles on pulse oximetry for screening newborns for cardiac disease. For me, the most interesting article is one on the recent change of course in China's health reforms to put emphasis on private hospitals. The authors of the review, from Oxford and Harvard universities, say this move is a retrograde and negative step that will run counter to many of the other recent reforms that aim to encourage equity and more efficiency in China's user-pays hospital based system.

The Lancet also includes several articles on the theme of preventing chronic diseases such as obesity - a very timely issue as China becomes more wealthy and starts to see the same lifestyle diseases such as diabetes that are already so common in more developed countries.

For me the other interesting section in this China-themed Lancet is the letters page. There are several letters from doctors in China commending the journal for highlighting the problem of violence against medical staff in China - and all put the blame on the underfunded health system and overworked doctors. On a related theme, doctors in China also lament the drop-off in applications for medical school - few young Chinese want to become doctors these days, as it is seen as a difficult and dangerous job that requires many years of study for little reward.

And any coverage of the medical situation China would not be complete without comment on the difficult status of organ transplantation. Quite a few doctors take issue with a recent Lancet article claiming that 'a new era' in organ donation is about to begin. They point out that China has about 200,000 require an organ transplant but there are only about 2000 donors. Read the full article to find out why.

My only criticism of the Lancet China issue is the too-deferential interview with China's health minister Li Bin, who gets to trot out all the claims of progress with reforms, without really being challenged about the many problems and contradictions with them. Oh, and the omission of any coverage of primary care [or lack thereof] in China ...

Wednesday, 27 August 2014

In China's hospitals, one in three doctors have latent tuberculosis infection

by Michael Woodhead
It's an avoidable occupational hazard that Chinese doctors could well do without: tuberculosis. 

A  study carried out in a general hospital in Henan has found that one in three healthcare staff have latent tuberculosis infection. The figures are even worse for a nearby infectious diseases hospital where almost 60% of doctors had latent tuberculosis infection.

First some clarification: as the CDC points out:

Persons with latent TB infection do not feel sick and do not have any symptoms. They are
infected with M. tuberculosis, but do not have TB disease. The only sign of TB infection is a
positive reaction to the tuberculin skin test or TB blood test. Persons with latent TB infection
are not infectious and cannot spread TB infection to others. Overall, without treatment, about 5 to 10% of infected persons will develop TB disease at some time in their lives.

So, people with latent TB do not pose a serious risk to patients, but they themselves face a high risk of developing active tuberculosis disease.

In the study of 712 healthcare workers at a 1600-bed general hospital and a 600-bed infectious diseases hospital in Zhengzhou, researchers found that the tuberculin skin test-positive prevalence was 34% in the general hospital and 58% in the infectious disease hospital.

Dr Zhou Feng and colleagues who did the study said that health staff faced high risks of tuberculosis if they worked with infected people, such as those with HIV who often have co-infection with tuberculosis. Rates of infection were also highest in staff with longer years of working in the hospitals, presumably due to greater duration of exposure to risk.

Writing in PLOS One they said many staff did not use personal protective equipment such as  face masks and N95 respirators when working with infectious patients, despite this being recommended in guidelines.

Another problem with detecting and treating tuberculosis in healthcare workers was the low rate of tuberculin skin testing for the infection: many healthcare workers refused testing, and the most effective testing kits were too expensive for many Chinese hospitals. The findings also highlighted the limitations of the regular chest X-rays used to screen workers for active tuberculosis disease.

As the authors conclude - more emphasis is needed on observing and adhering to basic infection control and prevention practices in Chinese hospitals:

"Comprehensive guidelines should be developed for different types of medical institutions to reduce tuberculosis transmission and ensure the health of healthcare workers," they suggest.

Tuesday, 26 August 2014

What the Chinese can learn from Tibetans about hypertension

by Michael Woodhead
I've always wondered why Tibetans could be so healthy when they seem to subsist on a diet composed of dairy and meat, perhaps with the odd potato thrown on the fire. 

One of the staples of the Tibetan diet is tsampa - the butter 'tea' which is more like a salty yak butter tea-milkshake. This is not your EasyWay shake - tsampa is made with barley and is often accompanied by a glob of fermented yak milk sometimes known as kurut - similar to the products seen in Xinjiang.

Now it seems there is a hidden healthy component of Tibetan dairy products that has powerful antihypertensive properties, as strong as the drugs prescribed by western cardiologists. The blood pressure lowering effects come from the fermented milks produced by 259 Lactobacillus helveticus - a kind of probiotic ACE inhibitor if you like. Something in the Lactobacillus has potent effects on Angiotensin Converting Enzyme (ACE), the same system that is the target of modern antihypertensives such as enalapril.

In a recent study conducted by dairy technologists at the Inner Mongolia Agricultural University, Huhho, the fermented milk product was found to contain antihypertensive peptides that lower blood pressure by about 12 mmHg for six to 12 hours. That is fairly impressive BP lowering - and would be useful in a typical hypertensive patient with a systolic BP of 140/95mmHg who wanted to get to a target of 120mmHg.

As well as keeping Tibetans healthy, Dr Chen Yongfu and colleagues say the newly-identified probiotic/peptide may have potential as "a valuable resource for future development of functional foods for hypertension management."

Monday, 25 August 2014

Beijing introduces private health insurance for primary care

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

Sunday, 24 August 2014

Why Chinese patients are turning against their doctors: contrasting articles by the New Yorker and BMJ

by Michael Woodhead
Two very interesting and very different articles this week on violence against doctors in China: one in the New Yorker and another in the form of a study in the BMJ Open

The New Yorker story is in the usual stylish narrative, but I prefer the BMJ Open article, because it has more facts and more insights, even if it is a dry scientific paper. In the New Yorker, writer Chris Beam uses the example of the murder of a doctor in Harbin to shine some light on the whole fraught situation of violence against doctors in China. The story focuses on the case of a young man from a small town who had debilitating and degenerative back pain (ankylosing spondylitis) and who was unable to get satisfactory treatment from a Harbin hospital. He also had TB, which made treatment with an immunosuppressive drug even more difficult. Frustrated at his patchy and expensive treatment, the young man returned to the hospital and attacked the first doctor he could find, and killed an 'innocent' medical practitioner who had nothing to do with his care.

Chris Beam tells the story well and uses it to give some background on the health system in China and why so many patients and their families turn violent when they are treated so badly. However, I found the article was a bit too focused on the legal side of things (the American obsession with law once again?) The article doesn't really explore the root causes of violence: the built-in pressure in the system to overprescribe and over service, the rising cost of treatment and the hugely overloaded hospital system. Beam does cover China's health reforms, but strangely fails to mention the recent moves to encourage private clinics and the use of primary care clinics.

Another factor not really touched on by the New Yorker article is the patient/family faults: for me some of the key factors in China's medical disputes are rising expectations combined with ignorance (poor health literacy) and readiness to use brute force. This is not just confined to health: see how Chinese travellers behave when flights are cancelled or hotel rooms are overbooked.

That's why I prefer the BMJ Open article by Dr Jiang Yishi and colleagues at the School of Public Health, Fudan University, Shanghai. Their article takes a look at the reality of the complaints systems that exist in Chinese hospitals - and finds them sadly wanting. Dr Jiang and colleagues undertook the first in-depth study of how the complaints system works for patients and for doctors and hospital staff. They conducted interviews with all 'stakeholders' and found that in many cases, the system is broken. In theory, a patient with a grievance has several channels through which they can seek redress. They can make a formal complaint to the hospital complaints office and can also petition via a system of 'letters and visits'. Patients can also go to mediation by a third party office to settle an unresolved dispute with a hospitals. And patients can also take legal action against a hospital via  a lawsuit.

In practice, these systems often do not work. Firstly, many patients are simply unaware of the complaints system and how to use it. Hospitals don't advertise their complaints offices, which are often hidden away in an obscure corner of the building. The staff in these offices are supposed to be able to investigate complaints and arrange mediation - but in practice they are often unqualified to adjudicate on complicated clinical matters, and they are also under great pressure to deflect complaints - or dismiss them quickly. Complaints departments are understaffed and have little sway in the hospital system. Another problem with the 'complaints office' system is that it lacks transparency. Patients make complaints but they get little feedback from complaints office staff who do everything 'behind closed doors'.

On the other hand, hospitals and medical staff also express great frustration about the complaints system. Doctors say any complaints arise because they work under great pressure to see 60 or more patients in a morning and don't have time to put on a 'warm face' or to explain things in detail to patients. This lack of connection and communication leads to many misunderstandings and unhappy patients.  Doctors also say that they become the scapegoat for failings of the system: for example, (just as in the US) they are restricted in what treatments they can offer to patients by the medical insurance rules - but patients don't understand this and often get angry at being denied treatments are given treatments that come with a hefty out of pocket costs.

Another big frustration for doctors and hospitals is the rise in unreasonable complaints and the use of abuse and pressure (extortion) to get a complaint resolved with financial compensation. More than 50 doctors interviewed mentioned this 'chao' (吵, argue) phenomenon. Doctors said many patients and relatives had unrealistic expectations about what could be done by medical staff. And when things didn't have a good outcome, patients and relatives often turned to threats and 'mob tactics' to put pressure on doctors and hospitals. These unruly groups are not interested in facts or a fair settlement but want to cause as much trouble as is needed to get a financial payout.

The BMJ Open article says the whole health complaints system in China is lacking in structure and rigour: there are no standard protocols for investigating complaints, for assessing harm and no data is collected on complaint numbers or how they are followed up - and no system for using complaints to identify weaknesses or errors and give feedback accordingly. Hospitals have no incentive to collect or document complaints because it just gives them more 'black marks'. 

The overall impression of the health complaints system is that it is perfunctory and ineffective: hospital directors want complaints to be managed quickly and made to 'go away', hence the readiness to make a quick financial settlement and avoid trouble and bad publicity, especially when angry mobs are involved.

The article by Jiang concludes by identifying three crucial areas where improvement is needed in the complaints system: organisational support, personal support from hospital managers and political leaders (and patients) - and learning system to ensure that failures are identified and rectified. The solutions put forward are sensible and obvious - and the full paper is well worth a read. 

However, I  would not be optimistic about the prospects for change: many of the problems that plague the health complaints system are common to those of Chinese society in general: there is a lack of trust in institutions (in this case hospitals and health departments) which are not accountable, lack transparency and which combine vested financial interest with political power. The solutions require open-ness, accountability and an independent watchdog with teeth. In the current environment in China, those are not likely to happen. Instead, China has top-down directives to crack down on the symptoms of these failings - the government issues stern warnings and makes some highly public arrests of wrongdoers. Ultimately it will take workable systems to fix the problems of health grievances, not campaigns and punishments.