In recent years, the number of patients with common and frequent illnesses has increased to 80% in primary schools.
In recent years, the policy has continued to increase the training of general practitioners, trying to use this as a breakthrough to strengthen grass-roots forces, forming the "first line of defense" for residents to seek medical treatment.
But this series of favorable policies are aimed at public institutions such as community hospitals and community health centers. Private clinics, which make up one-third of primary health care organizations, are not included.
It's easy to see why. As the only social health institutions, clinics are small and numerous, flexible and convenient services, which have improved access to health care services, but also brought a series of regulatory challenges, and in the past few years, the black clinics have been the focus of the fight against the illegal practice of medicine, and the rectification of the order of medical care.
In the current "public hospital" as the main health care system, the clinic still seems extremely "insignificant".
With the country's economic development into the stage of high-quality development, health care reform into a critical moment, clinics gradually into the eyes of the decision-making level, has introduced a series of favorable policies, hoping to promote the development of clinics. General practice clinics, in particular, have been given high hopes by some people - looking forward to being able to, as in Western countries, guide ordinary patients to adjust the pace of their frequent trips to major hospitals through clinics spread across the country and rich in features.
In this process, the positioning of the clinic but there has always been a "knot". In China, the individual clinic is to provide specialized medical services, its access and approval is also based on the standards of specialized clinics. "But primary care is often required to address comprehensive, diverse, and multiple health problems." Lv Fengping, founder of the Dr. Lv community clinic chain in Chengdu, told Healthworld that the day-to-day work of a specialty clinic, especially an internal medicine clinic, is actually no longer very different from that of a general practice.
The positioning of specialties conflicts with the generalist function that clinics need to play, which prevents them from playing a bigger role in hierarchical diagnosis and treatment.
In recent years, the state is vigorously training general practitioners and encouraging them to open general practice clinics. But it takes 10 years to grow trees and a hundred years to train people, and the cultivation of medical talent is far from a one-time effort.
In this process, many experts and practitioners suggested that it would be more efficient to promote the transformation of existing qualified and better quality specialty clinics into general practice clinics, and to facilitate the addition of the scope of practice of general practitioners by their practicing doctors.
China's clinics are registered mainly as specialties but mostly operate in general practice
Playing the role of "gatekeeper" for primary health care institutions is a common practice among countries, especially in the Western developed countries, to control the rapid rise in health care costs, to realize rational and orderly access to medical care for patients, and to improve the efficiency of the overall health care delivery system.
"In developed Western countries, more than half of the medical staff are general practitioners, taking care of more than 50% of the medical service supply." Shen Zhiwei, who is responsible for clinic business development at Honghua Healthcare, told the health sector that private general practice clinics, especially those founded by general practitioners, dominate primary healthcare, providing not only basic diagnostic and treatment services, but also public **** health services such as immunization programs, health education, and management of chronic illnesses, addressing most of the health needs of residents and building the "first line of defense" in healthcare services. The first line of defense for medical services is constructed.
In Japan, large hospitals, especially university hospitals, do not accept patients who come directly to the hospital, and usually need to make a first visit to a private clinic, and find that it is not possible to diagnose and treat the patient before making an appointment to refer the patient to a large hospital.
In Singapore, private GP clinics undertake 80% of primary care outpatient services, with the remaining 20% provided by public organizations. Public polyclinics, which target low-income groups and serve as referral points for tiered care, are less expensive than private clinics, have longer waiting times, and do not have the option of choosing their own doctors and expensive medications.
In China, primary health care institutions include community health centers, township health centers, clinics and village health offices. Of these, the first two, and even the village health center in the strictest sense, are government-related institutions - only the clinic is a socially-run medical institution.
By the end of June 2020, there were more than 1 million healthcare organizations nationwide, and 960,000 primary healthcare organizations, of which 249,000 were clinics, accounting for one-quarter of the country's total and nearly one-third of the grassroots level, and showing year-on-year growth, making them a major provider of healthcare services in all but name.
"Compared with government-run institutions such as community health centers, clinics are market institutions run by individuals, and in order to survive and develop, operators must strengthen their management, improve the medical environment, and improve the quality of their services, such as opening longer and providing more diverse services, while also trying to offer better prices as a way to attract more patients. " According to Lv Fengping, small and exquisite, grounded, convenient and with a certain degree of privacy are the advantages of the clinic.
Lv Fengping resigned from a public hospital in 2005 and opened his first internal medicine clinic in Chengdu's high-tech district. "At that time, I felt that it was too costly for many people to travel all the way to a tertiary hospital for a minor illness, and they would save a lot of trouble if they had a reliable medical institution at their doorstep."
After more than a decade of development, Dr. Lv's community clinics have grown to 40 in Chengdu, and Lv Fengping believes that he has initially realized his "original intention": the clinic not only provides residents with common diseases, common illnesses diagnosis and treatment services, but also helps residents to interpret physical examination reports, popularize health knowledge, etc., and gradually develops into the whole management platform for the residents' health. The company's website has been developed to provide a platform for the management of the health of the residents.
This is also the role and positioning of the clinic according to Lv Fengping, who believes it is no different from a Western general practice.
But most clinics like Lv's in China are registered as internal medicine clinics, not general practice clinics, which limits their ability to provide general medical services to residents.
For a long time, China has positioned individual clinics to provide specialized medical services, and access to and approval of individual clinics is also based on the standards of specialized clinics. Therefore, the vast majority of clinics currently provide only basic medical services in a specific area.
Related surveys in 2019 showed that the top three subjects in China's clinics are currently internal medicine, surgery, and dentistry. Since the subject of general medicine was not set up in the country in the early days, and only a few cities, such as Shanghai and Guangzhou, have opened up the subject of general medicine at present, the number of truly registered general medicine clinics in the country is extremely small.
In practice, it is very easy for specialty clinics to exceed their "scope" of practice in their daily diagnosis and treatment. For example, unregistered pediatric internal medicine clinic to receive children patients, unregistered surgical internal medicine clinic for emergency bandages, etc., which on the one hand may be the existence of the clinic's interest in the consideration of the factors, but more reasons for the primary health care is a very strong comprehensive, need to meet the people's diverse needs for diagnosis and treatment.
"The clinic is directly facing the people, and needs to solve their various health demands." Lv Fengping told the health sector, the people as long as they trust a clinic, he what disease will choose to first come to the clinic to consult, will not be divided into what section.
In her opinion, primary healthcare organizations like clinics, which are mainly designed to treat common and frequent diseases, should naturally be "generalist" so that they can truly solve people's problems. "The same goes for other clinics, because if you can't diversify your services to the population, you slowly lose patients."
It's true that many clinics, especially internal medicine clinics, are actually acting as general practice clinics, especially in the counties and townships where this is more obvious, and even some clinics are taking on some of the public **** health services. Fujian Dongqiao Economic Development Zone Community Health Service Center Huang Youxue wrote an article as early as 2013, calling for individual clinics to be included in the Community Health Service Center Chronic Disease Health Management, to enhance the level of chronic disease health management.
While the scope of practice of these organizations has not yet been "broken through" at the policy level, functionally, it is precisely the same as that of general practice clinics in Western countries.
It can be seen that China's specialty-based clinics set up positioning, and its function of providing full-caliber, complex basic medical and health services, there is a contradiction, and this is not conducive to the clinic in the hierarchical diagnosis and treatment of the role it could have played.
Promoting the transformation of existing specialty clinics into general practice clinics
In order to enhance the service capacity of primary care, the state is currently working to build a team of general practitioners, hoping to transform the primary care service model and promote hierarchical diagnosis and treatment through the professional population.
The Guiding Opinions on Promoting the Construction of a Graded Diagnosis and Treatment System, issued in September 2015, calls for the multi-channel training of general practitioners through the transfer of physicians on duty at the grassroots level, directed training of general practitioners, and upgrading of physicians on duty at the grassroots level, among other ways, while the Opinions on Reforming and Improving the Mechanism for Cultivating and Utilizing Incentive Mechanisms for General Practitioners of the General Council of the State Council, issued in 2018, encourages general practitioners to independently set up individual clinics or partnerships. doctors to independently run individual clinics or partnership clinics.
However, there are still fewer general practice clinics in grassroots organizations. This is partly due to the small number of qualified general practitioners in the country, and partly probably related to the specialist orientation of the clinics themselves.
"Most of the general practitioners currently being trained are still going to public hospitals, and there are still not many who really stay at the grassroots level." A medical administrator at a tertiary hospital told the health sector that general practitioners also need standardized training like other disciplines, and there is a fundamental contradiction in the training of general practitioners in public hospitals - tertiary hospitals rarely encounter the common diseases and conditions that the grassroots need to cope with, and general practitioners who undergo training in tertiary hospitals
For current specialist clinics that want to provide general practice services, their practitioners must obtain a general practitioner's certificate, and the prerequisite for obtaining the certificate is that they must spend three years in a major hospital full-time for standardized training. "Practitioners in clinics struggle to survive every day and simply don't have the time or inclination to spend so much time getting this license." Clinic Help Founder, Changde Ko, told Health.
In this case, some experts and related practitioners suggested that the country urgently needs to rethink the positioning and classification of clinics, change the specialty positioning of clinics or guide existing specialty clinics, especially internal medicine clinics, to transition to general practice. After opening this "door", in order to revitalize the existing large number of private clinics, so that the private medical resources into the primary health care system, and for the effective blood transfusion.
The key is to stimulate the enthusiasm of the specialist clinics, and in the process try not to increase the workload of the clinics. For example, specialist clinics can be selected on merit for pilot projects, and they can be trained in general practice through socialized training and distance training, encouraging clinic practitioners to learn general practice after work, enriching the strength of general practitioners and clinics, and upgrading the level of primary care services.
"The current level of development of China's clinics presents a 'small at both ends, large in the middle' carrot type - the number of exceptionally good and exceptionally poor is very small, and most of them are at a medium level. " Ke Changde believes that the clinic level of good and bad or clinics are not important reasons for the government's attention. Therefore, it is important to select excellent clinics to pilot the transformation of general practice, especially those with a high rate of repeat visits.
No matter what the policy is, the iron needs to be hard. "If the state can give us the status of a general practice, we can provide more comprehensive and diverse services to the people in an honorable way." Lv Fengping believes that, but no matter how the positioning ultimately, as a primary health care organization, constantly improve the level of medical care, and strive to provide the people with high-quality, convenient medical services of the original intention can not change.