Sunday, 20 December 2015

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


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

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

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

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

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

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

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

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

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

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

Sunday, 13 December 2015

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

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

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

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

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

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

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

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

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

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

Sunday, 6 December 2015

Shanghai hospitals to ban antibiotic infusions for coughs and colds

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

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

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

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

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

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

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

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

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

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

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

Thursday, 3 December 2015

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

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

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

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

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

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

As a commentator in Caixin magazine concludes:

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