It has been 11 years since the new medical reform was implemented. The basic path of this round of reform with "graded diagnosis and treatment" as its main purpose is to establish a general practitioner system and treat 80% of common and frequently-occurring diseases through contracted family doctors. Patients stay at the grassroots level, which alleviates the problem of "difficulty and expensive medical treatment" in large hospitals.
In recent years, policies have continued to increase the training of general practitioners, trying to use this as a breakthrough to strengthen grassroots forces and form the "first line of defense" for residents to seek medical treatment.
However, this series of favorable policies are all aimed at public institutions such as community hospitals and community health service centers. Private clinics, which account for one-third of primary health institutions, are not included.
This is not difficult to understand. As the only social medical institution in grassroots health institutions, clinics are small in scale, large in number, and provide flexible and convenient services. Although they have improved the accessibility of medical services, they have also brought about a series of regulatory problems. In the past few years, black clinics have been the main focus of cracking down on illegal Key targets for practicing medicine and rectifying medical order.
In the current medical system where "public hospitals" are the mainstay, clinics still appear to be extremely "insignificant".
As the country’s economic development enters a stage of high-quality development and medical reform enters a critical moment, clinics have gradually entered the attention of decision-makers, and a series of favorable policies have been introduced in the hope of promoting the development of clinics. General practice clinics, in particular, have high hopes from some people - they hope to be able to guide ordinary patients to adjust their pace of going to large hospitals through clinics with rich functions across the country, like in Western countries.
During this process, there has always been a "knot" regarding the positioning of the clinic. In our country, individual clinics provide specialist medical services, and their access and approval are also based on the standards of specialist clinics. "But primary care often needs to solve comprehensive, diverse and frequent health problems." Lu Fengping, founder of Chengdu Dr. Lu community clinic chain, told the health industry that the daily work of specialist clinics, especially internal medicine clinics, is actually the same as that of general practice clinics. Not much difference.
There is a certain conflict between the positioning of specialists and the general functions that clinics need to perform, which prevents clinics from playing a greater role in hierarchical diagnosis and treatment.
In recent years, the country has been vigorously training general practitioners and encouraging them to open general practice clinics. But it takes ten years to cultivate trees and a hundred years to cultivate people. The cultivation of medical talents is far from a temporary achievement.
In this process, many experts and practitioners suggested promoting the transformation of existing qualified and high-quality specialist clinics into general practice clinics to facilitate their practicing doctors to add general practitioners' scope of practice. Or a more efficient way.
Clinic registration in my country is mainly for specialists but mostly general practices
Playing the "gatekeeper" role of primary medical institutions is an important step for countries, especially Western developed countries, to control the rapid rise in medical costs. , a common practice to achieve reasonable and orderly medical treatment for patients and improve the efficiency of the overall medical and health service system.
“In Western developed countries, more than half of medical staff are general practitioners, responsible for more than 50% of the medical service supply.” Shen Zhiwei, who is responsible for the development of clinics at Honghua Medical, told the health industry, especially Private general clinics founded by general practitioners occupy a dominant position in primary medical care. They not only provide basic diagnosis and treatment services, but also provide public health services such as planned immunization, health education, and chronic disease management, solving most of the residents' problems. Health needs constitute the “first line of defense” for medical services.
In Japan, large hospitals, especially university hospitals, do not accept patients who come directly to the hospital for treatment. They usually need to have a first consultation in a private clinic, and only when they find that diagnosis and treatment cannot be carried out, they will make an appointment in advance to introduce the patient. Enter a big hospital.
In Singapore, private general clinics provide 80% of basic medical outpatient services, and the remaining 20% ??are provided by public institutions. Compared with private general clinics, public general clinics mainly target low-income people and serve as referral points for hierarchical diagnosis and treatment. Their costs are lower than private clinics, the waiting time is long, and they cannot independently choose doctors and expensive drugs.
In my country, primary medical and health institutions include community health service centers, township health centers, clinics, and village clinics. Among these institutions, the first two, and even village clinics in the strict sense, are government-related institutions—only clinics are private hospitals.
As of the end of June 2020, there were more than 1 million medical and health institutions nationwide, including 960,000 primary medical and health institutions, of which 249,000 were clinics, accounting for a quarter of the country. One-third of the total, and is growing year by year, making it a veritable major provider of medical services.
“Compared with government-run institutions such as community health service centers, clinics are market institutions organized by individuals. In order to survive and develop, operators must strengthen management, improve the medical environment, and improve service quality, such as opening hours. It should be longer, provide more diversified services, etc., and at the same time, it should be as affordable as possible to attract more patients. "Lu Fengping believes that small and exquisite, down-to-earth, convenient and private, etc. are all the advantages of the clinic. .
Lu Fengping resigned from a public hospital in 2005 and opened the first internal medicine clinic in Chengdu High-tech Zone. "At that time, I felt that many ordinary people had to go all the way to tertiary hospitals for minor illnesses. The cost was too high. If there were reliable medical institutions at their doorsteps, they would save a lot of trouble."
After ten years, After several years of development, Dr. Lu's community clinics have grown to 40 in Chengdu. Lu Fengping also believes that he has initially realized his "original intention": the clinic not only provides residents with diagnosis and treatment services for common diseases and frequently-occurring diseases, but also helps residents interpret physical examination reports and popularize medical services. Health knowledge, etc., are gradually developing into a comprehensive management platform for residents’ health.
This is also what Lu Fengping believes is the role and positioning of clinics. She believes that this is no different from general practice clinics in the West.
However, most clinics like Lu Fengping's in China are registered as internal medicine clinics rather than general practice clinics, which also limits their ability to provide general medical services to residents.
For a long time, my country has positioned individual clinics to provide specialized medical services, and the admission and approval of individual clinics are also based on the standards of specialist clinics. Therefore, most clinics currently only provide basic medical services in a specific field.
Relevant surveys in 2019 show that the top three subjects in Chinese clinics are internal medicine, surgery, and dentistry. Since there was no general practice subject in China in the early days, and currently only a few cities such as Shanghai and Guangzhou have opened general practice subjects, the number of actually registered general practice clinics in the country is very small.
In practice, it is very easy for specialist clinics to practice beyond the "scope" during daily diagnosis and treatment. For example, a medical clinic that is not registered as a pediatrician receives pediatric patients, and a medical clinic that is not registered as a surgical department performs emergency bandaging. This may be due to the interests of the clinic, but the main reason is that primary medical services are extremely comprehensive. It is necessary to meet the diverse diagnosis and treatment needs of the people.
“Clinics directly face the people and need to solve their various health demands.” Lu Fengping told the health industry that as long as people trust a clinic, they will choose to come to the clinic for consultation first for any disease. What subjects will it be divided into?
In her opinion, grassroots medical institutions such as clinics, which focus on common diseases and frequently-occurring diseases, should naturally be "general practitioners", so that they can truly solve people's problems. "The same goes for other clinics, because if you can't provide diversified services to the public, you will slowly lose patients."
Indeed, many clinics, especially internal medicine clinics, actually serve as The role of general practice clinics is more obvious, especially in counties and townships, and some clinics even undertake some public health services. Huang Youxue from the Community Health Service Center of Dongqiao Economic Development Zone in Fujian wrote an article as early as 2013, calling for individual clinics to be included in the chronic disease health management of community health service centers to improve the level of chronic disease health management.
Although the scope of practice of these institutions has not yet received a "breakthrough" at the policy level, from a functional point of view, it is exactly consistent with the functions performed by general practice clinics in Western countries.
It can be seen that the positioning of specialty-based clinics in my country is inconsistent with its functional positioning of providing full-scale, comprehensive basic medical and health services, and this is not conducive to the performance of clinics in hierarchical diagnosis and treatment. play a role.
Promote the transformation of existing specialist clinics into general clinics
In order to enhance the service capabilities of primary medical care, the country is currently working hard to build a team of general practitioners, hoping to transform through professional groups The grassroots medical and health service model promotes hierarchical diagnosis and treatment.
The "Guiding Opinions on Promoting the Construction of a Hierarchical Diagnosis and Treatment System" issued in September 2015 requires that through multiple channels, such as transfer training of on-the-job doctors at the grassroots level, targeted training of general practitioners, and improvement of the academic level of on-the-job doctors at the grassroots level. Train general practitioners. The "Opinions of the General Office of the State Council on Reforming and Improving the Incentive Mechanism for the Training and Use of General Practitioners" issued in 2018 encourages general practitioners to independently open individual clinics or partnership clinics.
However, there are still few general practice clinics in primary institutions. On the one hand, the number of qualified general practitioners in the country is relatively small, and on the other hand, it may also be related to the specialty positioning of the clinic itself.
“Most of the general practitioners trained at present still go to public hospitals, and not many actually stay at the grassroots level.” A medical manager at a tertiary hospital told the health industry that general practitioners also need to be like other doctors. There is a fundamental contradiction in the standardized training of general practitioners in public hospitals - tertiary hospitals rarely encounter common diseases, frequently-occurring diseases and other conditions that need to be dealt with at the grassroots level. Doctors may still not have the skills to work at the grassroots level.
For current specialty clinics, if they want to provide general practice services, their practitioners must obtain a general practitioner certificate. The prerequisite for obtaining the certificate is that they must spend three years full-time in a large hospital for standardized training. . "Clinic practitioners are working hard for survival every day and have no time or thought to spend so much time taking this certificate." Ke Changde, founder of Clinic Bang, told the health industry.
In this case, some experts and related practitioners suggest 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 move towards General transformation. Only by opening this "door" can the large number of existing private clinics be revitalized, so that private medical resources can truly be integrated into the primary medical system and effectively provide blood transfusions.
The key is to stimulate the enthusiasm of specialist clinics and try not to increase the workload of the clinics in the process. For example, specialized clinics can be selected for pilot projects, and general practice training can be provided through socialized training, remote training, etc. Clinic practitioners can be encouraged to learn general practice knowledge after work, enrich the strength of general practitioners and clinics, and improve grassroots The level of medical services.
“The current development level of clinics in our country is like a carrot with ‘small at both ends and big in the middle’ – there are very few particularly good and particularly bad ones, and most of them are at the medium level.” Ke Changde believes that clinics The uneven quality may be an important reason why clinics are not taken seriously by the government. Therefore, it is necessary to select excellent clinics for general practice transformation pilots, especially clinics with high return visits.
No matter what the policy is, you must be strong when you strike. "If the country can give us the status of a general clinic, we can provide more comprehensive and diverse services to the people in an open and honest manner." Lu Fengping believes that no matter what the final positioning is, as a grassroots medical and health institution, we will continue to improve medical standards and strive to The original intention of providing high-quality and convenient medical services to the people cannot be changed.