Wei Wang

Editor-in-Chief of FMCH

China's General Practice Conference highlights review

Wei Wang

Editor-in-Chief ofFMCH

Editorial

China's General Practice Conference 2015 &The 13th Academic Annual Meeting of the General Practice Branch of the Chinese Medical Association were jointly held in September 2015 in Beijing, China. As part of our China Focus it was decided to publish some key commentaries delivered at the event. This year, 2015, is a crucial period for China's health care reform; although radical change is already underway, work is also starting for the next "Five-Year Plan" in relation to health care. The major objective this year is to put a hierarchical treatment classification system into practice, which will have a functioning Primary Health Care (PHC) system at its core.The problems assocated with the development of a Primary Health Care system in China have been well documented. In our last issue Drs. Xu and Wang [1] explained how an incorrect translation of the concept in China contributed to many negative consequences for PHC in China.They listed a number of the problems such as:

? Minimal or zero health insurance coverage for primary care

? Serious investment shortages in the PHC delivery system because it was seen as an inferior low cost system not worthy of further investment

? Lack of highly trained Primary Care Practitioners with many health workers in the sector not even having degree level health qualifications but many still using the title of doctor thus devaluing the title.

? Low income, low social status and prestige associated with working in PHC thus difficult to recruit top experts and candidates, with students more interested in studying specialisms as opposed to choosing General Practice GP as a career

? Lack of trust amongst the general public in PHC doctors driving them to seek out specialist care

? Predominance of advanced and hospital specialty care driving up costs relative to health outcomes

? Geographical concentration of health care funding, medical facilities, and medical-school – trained physicians in large cities and in tertiary hospitals that should be focused on specialty care but are often engaged in primary care issues driven by commercial reasons

? Resistance from medical schools and tertiary hospitals to set up a GP/family medicine (FM) department to train general practitioners (GPs)/family physicians (FPs)

? Resources of tertiary hospitals stretched because of demand while community health centers and township hospitals are often empty

? Lack of standardized GP Training Curriculum, and lack of primary care research and funding for same

The commentaries published in this issue point to the awareness of the challenges faced by China and how different stake holders are attemtping to address them. The contribution by Dr. Margaret Chan [2], Director-General of the World Health Organization gives an international view of the challenges and progress being made in China in the area. Dr. Chen Zhu [3],Vice Chairman of the National People's Congress discusses the level of political engagement with the issues. Finally, the piece by Dr. Wang Zhengguo et al. [4] and 12 other leading academics at top institutions in China points to increased buy in from the specialist care centers and tertiary hospitals. These articles are good examples of the importance of focusing health professional's attention in China Health Care Reform towards continuing efforts in finding ways of improving China's health care service across countryside as well as urban locations. These articles are good examples of how Chinese health care professionals' attention during the process of Health Care Reform is increasingly focused on improving health care delivery in rural as well as urban areas.

1. Xu GP, Wang JJ. Primary health care, a concept to be fully understood and implemented in current China's health care reform.Fam Med Community Health 2015;3(3):41–51.

2. Chan M. Opening speech at China's General Practice Conference. Fam Med Community Health 2015;3(4):75–77.

3. Chen Z. Address at China's General Practice Conference. Fam Med Community Health 2015;3(4):77–79.

4. Wang ZG, Wang C, Fu XB, Li LJ, Qiu GX, Chen XM, et al.Initiative on specialist support for the construction of Chinese General Practitioner System. Fam Med Community Health 2015;3(4):79–80.

Opening speech at China's General Practice Conference

Dr. Margaret Chan, Director-General of the World Health Organization

Dear Chen Zhu, Vice Chairman of the National People's Congress, Li Bin, Director of the National Health and Family Planning Commission of PRC, officials of the Chinese Medical Association, members of the General Practice Branch of the Chinese Medical Association, representatives of general practice, ladies and gentlemen:

For the first time in history the world's urban population outnumbers those living in rural areas, the number of people over 60 years of age is greater than those under 5 years of age, and chronic non-communicable diseases have overtaken communicable diseases as the main causes of death in the world. All of this is true for China too.

We have seen a revolution in information and communications technologies, the rise of social media and increased access to information in general, contributing to increased expectations and demands among the general public with regard to public health services. In China the development of universal coverage of health insurance has spurred people's demand for health care in recent times also.

We can all understand this. When we or our loved ones have health problems, we all expect to receive the best level of care possible.

All of these factors have increased the burden on health care systems. Meanwhile the cost for new therapies and new technologies is rising. For example, the cost of each new antitumor drug approved by the United States Food and Drug Administration in 2014 was over $120 thousand dollars per year per patient. Many new therapies are only effective for moderately prolonging patients' lives for relatively short periods. All of these factors have far-reaching impacts on the organization, delivery and financing of health care services.

I am very pleased to be addressing you today at the China General Practice Conference. The conference is being held during a key phase of China's health care reform initiative.

Worldwide, health care workers are looking to China to see how it goes about achieving its desire to provide safe, effective, convenient and affordable health care services to its 1.3 billion citizens.

Achieving this target will require in-depth health care reforms involving health care insurance, hospital management, essential drug policies, reimbursement systems, etc., but particularly the development of primary health care systems.

I am very grateful to Mr. Chen Zhu, Vice Chairman of the National People's Congress, and Ms. Li Bin, Director of the National Health and Family Planning Commission of the PRC and all the government officials and leaders attending this conference who have been leading these important reforms.I applaud you and thank you for leading this great health care reform process in China.

Like most countries in the world, China's health system focuses on acute disease management and hospital services. As disease burden is mainly because of chronic disease, which has taken over from acute disease, we should carry out real reforms from the initial idea to the organization and the delivery of health care.

Although China covers a vast geographic area, the distribution of health resources is uneven. The demands between urban and rural areas are different and this should be taken into consideration. China pioneered the 'barefoot doctor' service system. The system in its essence is similar to the concept of General Practice; our mission is to further develop the 'barefoot doctor' into a modern system of General Practice. I thank the representatives present here. Thank you for your contribution to our country and thank you for establishing the system of General Practice at the grass-roots level. This new system has the opportunity to be an example to the whole world.

Primary health care is the basis of the classification treatment model whereby diseases are classified according to their severity and difficulty-level for treatment. Different health institutions are responsible for diseases of different severity or difficulty-level. Most less-serious diseases will be treated in primary health care institutions which China is developing;the key point for success is a well-trained and energetic general practitioner community. China is fortunate to have the General Practice Branch of the Chinese Medical Association,devoted to developing the curriculum, standards and performance evaluation mechanisms for the discipline. The Chinese Medical Association is also developing a professional network platform. This platform will not only play a role in mainland China, but also in other regions. Dr. Meng-Chih Lee has successfully promoted the development of General Practice in Taiwan and I will continue to follow his work with great interest.

The establishment of a well-trained and motivated general practitioner community is a sensible method to help address the specific health challenges of the 21stcentury effectively and in a cost efficient manner. General practitioners provide both treatment and preventive services. They support early disease detection and treatment before patients develop complications resulting in the need for higher cost therapies and long-term hospitalizations. As the first point of access to health services,general practitioners have the ability to treat patients with minor conditions and thus prevent them from presenting at hospital emergency rooms and draining acute resources. They know that ill health can have medical or social causes, and thus they have the advantage of being able to provide primary prevention and enhance patient outcomes, they are best placed to provide real health care by focusing on the patients first.

Those who have paid attention to health care reform in China will have noticed that the lack of well-trained general practitioners is a major obstacle in decreasing the overuse of hospital health care services. This is because in China, medical education focuses on specialist physicians rather than on general medicine. Having identified the obstacle, it has been analyzed and evaluated though a pilot study. Most will be aware of the outcome. I would like to mention two of the findings here:

First, the general practitioner is regarded as 'second class citizen' compared with hospital doctors within the medical profession. This also influences the public's opinion; people can perceive the service provided by the general practitioner as similarly second-rate. This problem will persist for as long as this perception exists. General practice needs to be regarded and established as an independent discipline. As I already said, China is fortunate to have the Chinese Medical Association playing a leading role in the general practice arena.

Second, the general practitioner receives lower pay than those working in hospitals. The current reward model incentivizes over-prescription and over-intervention, instead of stimulating primary health care and prevention. Likewise most primary health institutions do not take full advantage of nurse practitioners. Giving adequately trained nurses the right to prescribe would be a valuable use of their skills for example.

Ladies and gentlemen, health care reform faces various difficulties and challenges. It requires the participation and efforts of the whole society. I congratulate Li Bin, Director of the National Health and Family Planning Commission of the PRC who is leading the reform team. I also congratulate all of you in trying to help me realize my dream for China. My dream is that when I retire from the position of Director-General of the World Health Organization and return to China, there will be an excellent general practitioner waiting to take care of me in my later life.

Thank you all!

Address at China's General Practice Conference

Chen Zhu, Vice Chairman of National People's Congress

This year marks the 70th anniversary of the end of World War II. It is also the 100th anniversary of the Chinese Medical Association's inception and this year has seen the fulfillment of the 12th "Five-Year Plan" of the People's Republic of China.At this important time, we should remember our history, learn from the past and look to the future. In China we are carrying out radical health reforms and, at the same time, making new plans for the next "Five-Year Plan" in relation to health care.During this process, the development of General Practice is receiving more and more attention and is embracing the considerable opportunities available.

Currently, most people in China, from the general public to clinical physicians, do not have a clear understanding of the concept of General Practice. Some perceive the general practitioner (GP) as someone with a low professional skill level while others believe that a GP can treat all kinds of clinical conditions. In reality, a GP works with a large number and variety of patients dealing with a broad spectrum of health issues. GPs are required to make accurate clinical judgments based on basic practical examinations and to recommend appropriate treatments. Likewise patient referral is also a crucial part of a GP's daily work. To be effective they need a broader medical knowledge of illness and the local disease spectrum than other clinicians. Other health professionals can be specialized whereas a GP needs to have an extensive knowledge base across every branch of medicine.

Furthermore, GPs need to have numerous different competencies. A GP has many responsibilities to their community, such as providing public health services, health education, psychological counseling and family planning amongst others. These tasks require a GP to have good communication and coordination skills. They must have the common touch to be able to communicate with people from varying backgrounds as well as with medical specialists. They need to have the ability to be a team leader within their clinical practice and to also act as community leaders. In addition, from a technological perspective, the rapid development of health information services makes the Chinese GP not only the direct manager of his patients' health records but also their gateway to emerging"Chinese Internet+" health services.

The conditions necessary for the development of general practice in China can be summarized as "the four points of unification". The first is the unification of basic health organizations and major hospitals. In-depth structural health reform has already begun in China. The implementation of treatment classification is a key point of this health reform. It requires GPs to work across a spectrum of health issues such as taking care of minor ailments of patients, referring patients for specialist treatment in a timely manner and managing acute and chronic diseases. This will also require the GP to act as a bridge within the medical service system between the needs of common people and the existing hospital system. Links between GPs and the existing medical service system must be built up. Strengthening General Practice at the grass roots level is crucial for health reform in China.

In September 2015 10 leading academic proposed an initiative to ask specialists from top tier hospitals to support the development of General Practice. This is exciting news but we still need to engage in fundamental reform of our health system. Once again, I am calling for the establishment of a Department of General Practice in every medical college or to have General Practice medicine categorized as a specialty in each Department of Clinical Medicine. In addition, it is necessary to establish a General Practice department in every tertiary-level hospital and teaching hospital affiliated to a medical college. To reconstruct the medical system, the government should encourage large hospitals, community health service centers and health clinics in towns and adjoining areas to unite to establish training bases for GPs. This will greatly assist the reconstruction of China's medical service system.We hope that the key government administrative departments across health, education, and finance could in the future look to use the development of General Practice as a core index for the assessment of medical colleges and organizations.

The second point of unification is the conversion and coalescing of clinical practice, medical education, and research. General Practice involves exposure to all forms of medical conditions and is directly connected with the delivery of clinical services.At the same time, it is an essential stage in every resident physician's professional training. General Practice is a natural point of coalescence for clinical practice, medical research, and medical education. As Translational Medicine is growing rapidly,General Practice is becoming increasingly important. I hope all general practitioners can focus their work to learn from international research and make the delivery and execution of general practice an outstanding feature of our country.

The third unification aspect looks to unite prevention and treatment. Rapid economic development leads to changes in the disease spectrum. Both chronic diseases and infectious diseases are increasing threats to health. Traditionally our big hospitals have focused on treatment, spending less time and money on prevention. GPs will play a leading role in health education and the early detection of disease. The GP is the key to implementing preventive health care guidelines. Building a strong base will help to further strengthen the GPs role in the management of chronic disease and infectious disease monitoring. This can be achieved through the establishment of departments of General Practice in big hospitals, using the local Health Alliance organizations to attract talented people for primary health care centers and to establish good evaluation mechanisms that incentivize positive health outcomes.

The fourth point of unification is the coalition of health care provision and societal development. As a "gatekeeper" of health, the GP is the person who can empower people to have access to health care. The global perception is that a good GP often enjoys a high level of prestige in the community and often come to assume a leadership role within communities. Such responsible GPs will not only be health providers,but will also play active roles as advocates and community leaders at the local level. Here GPs can work in tandem with local committees to promote community health initiatives and improve people's day-to- day quality of life. GPs will become an important force that is trusted by the people and relied on by the government to support and care for its people.

However, the successful development of General Practice in China does indeed face major challenges. We need to use the experience of other countries as a reference and move beyond our current situation. The support of related organizations in China is crucial to forging ahead. As the chairman of the Chinese Peasants' and Workers' Democratic Party,I have seen how the General Practice Specially Contracted Talents Training project which was jointly implemented by the Chinese Peasants' and Workers' Democratic Party and the governments of Bijie City (Guizhou Province), Guangxi Zhuang Autonomous Region and Ningde City (Fujian Province) have to date recruited 102 excellent people. The second recruitment drive is about to begin. In the future, my party will put additional support in place to implement the Chinese government's General Practice Specially Contracted Talents Training project at the grassroots level, utilizing the full resources of our party. We will fully support the new system to help attract outstanding GPs to the primary health care service system. The Chinese government is itself striving to achieve its target of having two to three GPs per 10,000 people by 2020. Recently the National Health and Family Planning Commission of the PRC began its work on the health reform plan to form part of the 13th Five-Year plan. They are deeply committed to the"Healthy China" concept. The reconstruction of the medical service system is seen as a priority landmark achievement in reaching the goals of a "Healthy China". In my opinion there is no doubt that the future development of General Practice is secure and that the future status of GPs in China will increase but it will require strenuous efforts to continue the process of thorough on-going health reform. The evolution of the"Healthy China" initiative will be a driving force towards a bright future for General Practice.

Hard-earned success makes the achievement more valued, I firmly believe that the drive across government departments at all levels and the support from other health workers will make General Practice in China a great success for all our citizens.

Initiative on specialist support for the construction of Chinese General Practitioner System

A medical service system with a clear hierarchy of care and proper allocation of resources assures the delivery of good medical services. Within this system, primary health care institutions have an important responsibility as "health gatekeepers". These institutions mainly undertake tasks such as: disease prevention, health management, rehabilitation, emergency treatment,and common ailments treatment. The range of human capital resources required include general practitioner (GP), clinical nurses, public health physicians (public health nurses) and others.

For some historical reasons, the primary health institutions in China have developed slowly, health workers' technical abilities tend to be lower and properly qualified GPs are in short supply. The Chinese government is further developing General Practice and adopting a system of "Graded diagnosis and treatment". With this background, as specialists from big hospitals, our initiatives are as follow:

1. Work to change the perception and support the development of general practice.

The GP is a doctor with a range of abilities and skills across the health spectrum. They have extensive knowledge, strong humanistic emotion and good communication abilities. They deserve respect from all medical staff members. They should be acknowledged across the whole of society for their unique skills and contribution to preventive health care and controlling health care costs.

2. Develop general practice as a discipline and train GPs.

Big hospitals should take the development of general practice to be their social responsibility and future mission. They must strive to create conditions for the establishment of general practice. Big hospitals should unite with adjacent community health service centers or health clinics in towns and townships to establish GP training centers. Apart from general practice work within the hospital, it is the big hospitals' responsibility to train our GPs, undertake scientific research and carry on GP's in-service training. Big hospital should also contribute to the establishment of a good GP team in their regions.

3. Establish a cooperation mechanism between GP and other health workers, and support classification of treatments.

The relationship between general practice and other medical disciplines is close. A mechanism which could help GPs and other specialists to have clearly assigned tasks, make them help each other and cooperate together should be established. Through various types of supporting work, we will try our best to improve the technical skill level of secondary hospitals, and then direct them to help primary health care institutions to improve skills and abilities. Through this process, the health care delivery ability of primary health institutions will improve rapidly. This will lead to building up local residents' trust, patients will look more to the primary health centers and the pressure on big hospitals will be released. Finally, the public will have a better experience when seeing a doctor in a big hospital.

Initiators:

Wang Zhengguo, academician of Chinese Academy of Engineering, specialist of Field Surgery

Wang Chen, academician of Chinese Academy of Engi neering,specialist of Respiratory Medicine and Critical Care Medicine

Fu Xiaobing, academician of Chinese Academy of Engineering,specialist of Trauma Medicine and tissue repair and regeneration

Li Lanjuan, academician of Chinese Academy of Engineering,specialist of Lemology

Qiu Guixing, academician of Chinese Academy of Engineering, specialist of Orthopaedics

Chen Xiangmei, academician of Chinese Academy of Engineering, specialist of Nephrology

Lang Jinghe, academician of Chinese Academy of Engineering, specialist of Obstetrics and Gynecology

Zhao Yupei, academician of Chinese Academy of Sciences,specialist of General Surgery

Zhao Jizong, academician of Chinese Academy of Sciences,specialist of Neurosurgery

Hu Shengshou, academician of Chinese Academy of Engineering, specialist of Cardiovasology

Zhong Nanshan, academician of Chinese Academy of Engineering, specialist of Respiratory Medicine

Cheng Jing, academician of Chinese Academy of Engineering,specialist of Molecular Diagnostics

He Jie, academician of Chinese Academy of Sciences, specialist of Thoracic Surgery