Monday, 25 April 2016

"Three Lows and One Missing" - Is China on target to deploy 700,000 general practitioners? (short answer: no)


Being a medical journalist in Australia, I've come across a few academics and leaders of medical groups who have marvelled at China's stated aim to deploy an additional half a million general practitioners by 2020. In a country where there are 25,000 general practitioners, the numbers are mind boggling and the ambitious target seems laudable. When I say that this may be an unrealistic goal given the current paltry state of primary/community care in China, I am viewed as a something of an overly-negative cynic or even vaguely racist.

It's therefore reassuring to see that my expectations are in line with those of the president of the China Medical Doctor Association, Dr Zhang Yanling. This month the CMDA chief was one of several big potatoes who showed up at the "2016 GP Training Forum and 13th Community Health and General Practice Annual Conference" held in Beijing on 23 April

The main speaker at the meeting was National Health and Family Planning Commission (NHFPC) Deputy Director Liu Qian, who said that creating a primary care system was one of the key aims of China's healthcare reforms. He said the creation of a primary care workforce was seen as an important step by top leaders such as Xi Jinping and Li Keqiang, who sent a message to the conference to make serious efforts to implement the policy.

Director Liu made the usual top bureaucrat exhortations to strengthen/promote/deepen reform of the medical education system to make this so. However, even he was realistic enough to admit that of the current 120,000 medical trainees only 13,000 (about 10%) were training as general practitioners and some of them may be hospital based rather than in community clinics).

He also acknowledged that China's entrenched doctor system was geared towards hospital-based specialists and that there was only weak support for general practitioners. There is no culture of primary care in China and this is reflected in the lack of training opportunities, low social status of community doctors "and the trust of the masses of trust is not high". Unsurprisingly, therefore, being a general practitioner is not a very attractive career option for any would-be doctor.

Director Liu then went on to make more of the usual remarks about strengthening the education system to train more general practitioners and making more efforts in this direction  etc etc

He was followed by Dr Zhang Yanling of the CMDA , who expanded on what the director said by coining the phrase the "Three Lows and One Missing". General practitioners suffer from "Low Pay, Low Motivation, Low Social Status and Missing Education" said Dr Zhang.

He said that in words, China's authorities had expressed strong support for the WHO-expounded principle of primary care and having general practitioners as gatekeepers to the hospital healthcare system. However in practice, general practice was weak, underdeveloped and had only patchy distribution across the country, he noted. While there are some general practitioners in bigger cities and in some regional hospitals, the biggest gap for primary care was in township and smaller county hospitals which were often both understaffed and underused. Dr Zhang used the Chinese saying "Swallows sitting in the doorway" to express the deserted state of China's township hospitals - because patients do not trust the doctors and take their illnesses straight to the bigger hospital "centres of expertise".

Dr Zhang said three things are needed to build a primary care system in China:

1. A commitment to build a large and sustainable primary care workforce based on teams of well trained general practitioners who are well remunerated and have a graded career pathway, similar to hospital doctors, rather than being in a dead end job.

2. A robust training system that ensures the primary care workforce is motivated and highly skilled - including the retraining and upskilling of allied health practitioners and physician assistants to make a primary acre team. Dr Zhang said the current projections were that China should have 1 GP for every 2000 citizens, which would require 700,000 primary care practitioners by 2020. However, based on current training capacity of 172,000 doctors and doctor assistants, there would still be a shortfall of 400-500,000 general practitioners by 2020.

3. Training pathways including residencies will need a partnership between government departments of health and education along with medical professional groups such as the CMDA. Working together they will need to establish a GP training group with well qualified educators that can set standards, plan training place numbers and oversee assessment and accreditation.

Dr Zhang concludes that a general practitioner primary care system is possible so long as there is good policy, clear commitment from government and cooperation from government departments, industry, the profession and good guidance from academics.

The two day conference also heard from a host of academics and experts in primary care from China, Hong Kong and and foreign countries such as Canada and Australia.

We wait in hope to see if the fine words of the conference delegates are actually matched with government funding and backed by policy that is actually implemented.

Sunday, 17 April 2016

Heathcare privatisation: China adopts the US model


Prepare for the Mayo Clinic with Chinese Characteristics. This year China is taking the first steps towards creating the equivalent of US group medical practices such as Permanente and the Cleveland Clinic.

The so-called "Doctor Groups" (Yisheng Jituan, 医生集团) are springing up around the country -  mostly in major cities of the affluent Eastern provinces. They are being set up in response to the loosening of the government's rules on how and where doctors can operate - clinicians are no longer tied to the tertiary hospitals and are now being encouraged to be 'fluid' and 'open'. In response, at least fifteen doctor groups have been set up in 2015 and 2016, usually based around one location and with one specialty.

These are not socialist collectives nor are they not-for-profit groups. Instead they are privately financed businesses that are being set up with large investments from major industrial players such as pharmaceutical companies. These are groups that are seeking profits and market share as a return for their investment. Not sure how PRC's Marxist theorists will explain this away.

A typical example is the Yibai Pharmaceutical Anhui Oncology Group. This covers ten leading cancer specialists and their staff, as well as specialist treatment facilities in the Anhui and Shanghai area - services that include diagnostic imaging, radiotherapy, microsurgery and chemotherapy. The pharmaceutical backer has invested hundreds of millions of dollars already and is hoping to use its industry experience and connections to package other services such as pharmacy, supply chain and IT services. According to an investment analyst, the Yibai group is hoping to make 500 million RMB profits within two years.

Yibai is just one example: others include the Medical Imaging Group - an alliance of imaging facilities covering 27 hospitals including the Beijing Union Medical College Hospital, and Beijing PLA General Hospital.

Another doctor group is United Lige, which has a looser structure covering many cities and provinces including Beijing, Tianjin, Shanghai, Chongqing, Jiangsu and Zhejiang. It aims to bring smaller groups of doctors together in private clinics under the Lige banner.

Others Doctor Groups include
  • Sanjia (Mobile phone referral, liaison etc services)
  • Mingyi Hui (a multi-speciaity consortium that aims to offer family care from children to the elderly, with an online/telehealth emphasis)
  • Song Dong Lei Neurosurgery Group (Shanghai)
  • Pumai Doctors Group (collaboration with Chow Tai Fook to set up polyclinics in Shanghai)
  • Yongchun Male PLastic Surgery Group ( Shanghai Woxin Hospital)
  • Fenlan/Huaxia Pathology Group (Set up with more than 120 pathologists in conjunction with the China Medical Association Pathology Society, this group has received 30 million investment and will provide specialist pathology services via a network of 60 hospitals).
  • Famous Doctor Fertility Group (Shenzhen based, set up by veteran Obstetrics and Gynaecology specialist Gong Xiaoming)
Most of the private doctor groups are financed by domestic companies, many with little healthcare experience. But rather than doing joint ventures with western healthcare companies to get foreign know-how, Chinese newcomers to private healthcare are simply buying up foreign healthcare providers. The Luye Medical Group recently bought the Australian private hospital consortium Healthe Care for $938 million. Luye's Charles Wang says the new doctor groups aiming to do business outside the big hospital environment lack operational expertise, and they are hoping to transfer such skills from the Australian outfit to the Chinese market.

This is what he told the Australian Financial Review:

"When things change in China, they tend to happen very fast. Doctors and practitioners forming their own doctor groups is something that never would have happened until last year. They are now leaving the public sector and forming their own groups, and once that gains momentum, you will see it rapidly become more westernised."

According to the AFR, the idea is not to parachute Australian executives into China, but to export the way Australians manage their hospitals, including finances, procurement, risk and clinical control.

"I expect you'll see, in time, structured medical programs, and we'll go up to China and do training and bring middle managers down here in Australia. In clinical areas there will be doctor mentoring and nursing programs,"  says Healthe Care's CEO Steve Atkins.

My own view is that it will take a lot to break up the power of the big hospitals. There are a lot of vested interests involved. The move to private doctor groups also raises the question of what impact this will have on the capacity of the existing public hospital system. If the most talented doctors can work outside the system, who will replace them? If top surgeons take two-three days a week doing private work, who will fill their positions in the public hospitals for clinical work and training?

There are many unknowns, but with official backing from the health minister and the Premier, expect to hear a lot more about Doctor Groups from 2016 onwards.

Tuesday, 12 April 2016

Health ministry gets serious about promoting TCM

If you have depression take a herbal infusion of daylily. If you have avian flu, use a few capsules of anti-cold Chinese herbs. These are just as effective and much cheaper than using western pharmaceuticals. That's the official advice from the National Health and Family Planning Commission this week.

At a press briefing organised in Beijing, the ministry's propaganda chief Mao Qun'an said that it was important to look at the public health advantages of using Traditional Chinese Medicine for fighting and reducing the burden of disease, as demonstrated by officials from Gansu province. He said the TCM promotion efforts of Gansu's health department were the "correct direction" and should be a model that other provinces can learn from.

He introduced TCM advocate Liu Weizhong from Gansu, who described how daylily was being sold by the ton in Gansu for the treatment of depression.

"Gansu is a poor province but we have harnessed the power of herbs such as daylily as a low cost way to manage disease in the population," he said.

"When Gannan Tibetan country has landslides many of the local people suffered from insomnia, anxiety and depression. We put two tons of day lily in 12 cauldrons, gave every person a paper cup and treated 7000 people at a cost of 1.4 yuan each. The depression was all gone," he said.

[A quick google search shows that daylily aka Hemerocallis is a traditional herbal remedy that contains active ingredients including clonidine - a drug for hypertension that can cause neurospychiatric effects].

Likewise Liu Weizhong claimed that avian flu, which caused many deaths and serious complications in China, could be easily and successfully treated with just three or four capsules of a Gansu TCM remedy that cost less than 200 yuan. This was much better than the regular medical treatment for avian flu that cost ten times as much, he said.

Another TCM panacea was the health prevention kit issued to households which consisted of a bag of salt, scrapers, plates, cupping utensils and a thermometer.

Liu Wenzhong said farmers were told to boil some fennel and pepper leaf and use this with the equipment as a cure for 13 kinds of disease, including cervical spondylosis, thyroid nodules, cough, pharyngitis, lumbar disc prolapse, frozen shoulder, arthritis, stomach pains, and especially senile prostatic hypertrophy.

These folk remedies might sound like old wives' tales. but they have the official backing of the State Council as well as the National Health and Family Planning Commission.

In February the State Council issued a "strategic plan for development of Chinese medicine," which said that with the ageing population "there is an urgent need to develop and make good use of Chinese medicine".

The NHFPC agreed, saying that Gansu was leading the way in developing TCM and putting it at the centre of healthcare.

Sunday, 3 April 2016

Three vastly different articles on medical disputes - which one gets closest to the truth?

Violent and disruptive medical disputes have become so common in China that they barely rate a mention in the media any more. There has to be something quite different about an attack on doctors for it to make the headlines these days. The recent incident in which a mob of disgruntled relatives of a former patient took over a Shenzhen hospital and forced doctors to kowtow to a 'shrine' was one such incident.

In response, the Chinese authorities have said they will now adopt a new zero-tolerance approach to such protests and attacks on healthcare staff.

"Vice Public Security Minister Huang Ming said police will crack down on hospital-related crimes and show zero tolerance to perpetrators who assault and injure medical personnel. He made the remarks at a meeting on safeguarding order at hospitals and promoting harmonious doctor-patient relations on Thursday."

Ho hum - we've heard it all before. Every time there is a violent attack on hospital staff there are pledges to crack down, strike hard etc etc. A few weeks later it is business as usual. As I've written on this blog before, nothing will change until the government addresses underlying reasons for these disputes: under-resourcing of hospitals leading to ridiculously high throughput of patients - 3 minute consultations in which patients are barely listened to and prescribed the most expensive treatments (so that the hospital can get a bigger profit).

According to the latest empty promise to 'take action' the minister Huang "ordered better settlement of medical disputes by taking precautions, conducting risk assessment and spotting and containing disputes at an early stage." Gee thanks.

The article also makes the implausible claim that the number of hospital-related cases of violence continued has fallen four years in a row, and is down 12.7 percent year on year. The reality is quite the opposite.

And while on the subject of propaganda, the Hong Kong based SCMP, always keen to peddle a  more palatable version of Beijing's policies to foreigners, this week has an interview with a doctor who believes the answer to medical disputes is in looking to China's history. In a Q&A article, journalist Zhuang Ping throws a few easy questions to Dr Yang Zhen, a surgeon and deputy chief of the hospital administration office in Shanghai’s Zhongshan Hospital.

Dr Yang says China should take a look at how doctors in China traditionally established good relations with patients. Other than a few glib statements about being nice to patients and showing a more human face, he doesn't explain how doctors will make this happen when they have to rush through 80-120 patients in one short shift ( and prescribe enough drugs to them to hit their salary bonus target). All pretty worthy sounding but meaningless, really.

The article with the greatest insight into China's medical disputes in published in an academic journal (Health Economics, Policy and Law) and is based on interviews with 12 doctors from a multitude of specialties working in Shenzhen.

Interestingly, the article starts off by directly contradicting the claims of the public security minister,  quoting figures from the China Hospital Association showing that the number of medical disputes has increased by about 20% a year.

"Once worshiped as ‘angels in white,’ members of the medical profession in China are facing unprecedented challenges. Due to the deteriorated public trust during the marketisation reforms of the last three decades, Chinese physicians are working in an antagonistic environment. Heavy workload, low remuneration, and tainted social prestige have left millions of physicians feeling undervalued and
made medicine a career to be avoided, a situation rarely seen in other Confucian societies," it notes.

The article makes several points about medical disputes that have been raised before - but also includes one new one that is unique and potentially game changing.

The authors say that whatever the causes, medical disputes are rarely settled through legal channels, despite there being an officially recommended dispute resolution pathway and laws that in theory should cover medicolegal areas of dispute. The reality is that patients and their families have found that they are much more likely to get results - and get them much faster - if they take matters into their own hands. In other words, mob rule. According to the article, aggrieved patients and relatives of those affected by medical misadventure have found that they can get financial compensation and see their grievances gain attention if they take violent and disruptive action against hospitals and their staff. In practice this means staging demonstrations, blockading departments - and even whole hospitals - and threatening staff. They do it because it works.

This is the testimony of one of the doctors interviewed:

"Because the macro political environment attaches paramount importance to the so-called
‘maintenance of social stability,’ hospital managers are very afraid of high-profile incidents because local government may blame them for failing to mitigate the tension. If payment can quench patients’ anger, hospital managers would certainly love to do that, even when the patients are obviously blackmailing them. Patients also know the hospitals’ mentality very well, and actually take advantage of it. Some have chosen to stage farcical protests because doing so best maximized their interests. In fact, they deliberately avoided legal resolution because they knew hospitals would satisfy their monetary demands anyway."

The article goes on to say that hospitals fear high-profile protests because of the detrimental impact on their reputation, (which would inevitably affect their income) and also the political mandate imposed by local government to avoid mass incidents.

"They are also generally reluctant to resort to legal channels as litigation will not only ruin their reputation, but also consume a great deal of energy and time. Many studies have identified private settlement as the most popular means of resolution, even when patients’ complaints are clearly
unreasonable," it says.

In a second part of the study, two thirds of 300 doctors surveyed described relations with patients as 'very tense' and a similar proportion (65%) had been physically assaulted at least in the previous year.

The authors of the study say there are several key lessons for preventing and managing medical disputes in China. First and foremost is the need to reduced doctors' workload to a level where they have time to interact with patients and spend a meaningful amount of time with patients to allow good communication, adequate assessment and diagnosis and explanation of medical matters so that patients can make 'informed choices'.

Secondly, there is an urgent need to remove the profit/bonus incentives for doctors so that they paid according to their performance on good clinical practice rather than on how many drugs they have prescribed.

The study authors have a rather bleak outlook about the possibility of curbing attacks on healthcare staff - at least in the short-to-medium turn:

"For decades, health policy reform proposals have always put financing reforms, realignment of provider incentives, or organizational restructuring first. However, the [medical dispute] crisis in China shows policymakers and advisors the detrimental consequences of hostile interactions between doctors and patients. While it is not unreasonable to expect systemic reforms to restore trust between the two parties, one must bear in mind that it may take much longer than anticipated to see the effects; in the meantime, the dysfunctional doctor–patient relationship continues to deteriorate," they conclude.