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.

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