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September 23, 2013

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GP system faces cynical patients, hospitals

Facing patient overload in hospitals, Shanghai was the first city in China to set up a system using general practitioners in neighborhood clinics as the front line of health care.

The GPs are supposed to act as gatekeepers, of sorts, to treat more minor maladies and do simple diagnostic tests in neighborhoods, and to channel more serious cases to cooperating hospitals for specialist care.

“About half of patients in big hospitals can be treated in the neighborhood,” said Chen Pei, president of the Tianlin Neighborhood Health Center. “But patients usually prefer big hospitals, which they believe have better capabilities.”

Indeed, many Chinese equate health care with hospitals. General practitioners, who are commonly the primary health care providers in Western countries and are required for referrals to hospital admission, are still relatively new to China. Shanghai introduced the neighborhood GP program in 2001 to try to ease the strain on hospitals.

Under the Shanghai program, residents are encouraged to sign service agreements with their neighborhood health centers, receiving basic health services and preventative care. The centers also function as inputs for the city’s health database.

The policy encourages people to visit GPs first when they have non-emergency medical problems. They pay no outpatient registration fee, as required in hospitals, and can access drugs at cheaper costs.

Serious cases are referred, presumably expeditiously and with little red tape, to hospitals linked to the clinics.

But does the system work to better allocate limited medical resources and ease the heavy workload in city-level hospitals, which are typically crowded?

So far, the results have been mixed.

Building confidence

To nurture public confidence in the GP system, the city has earmarked 10 percent of hospital specialists to act as fast-track referrals for 39 clinics on a trial basis. More neighborhood health centers will be added this year.

But in practice, many GPs fail to refer patients to the specialists. Or if they do, the wait can be long.

Wu Jun, director of the Jiangsu Road Neighborhood Health Center, said one GP at his clinic referred a patient to a specialist at the popular Huashan Hospital, and the referral has been languishing for more than one month.

“Even with an appointment number, a patient can wait for almost an entire day before seeing a specialist,” said Tianlin Center’s Chen. “Many patients haven’t really enjoyed any benefit from the system. In that event, they figure they might as well go directly to a big hospital and wait in the long queues rather than come here first.”

People can walk into any hospital with their medical smart cards, which contain insurance information, and seek help. They don’t need a referral from a general practitioner. So the situation persists: neighborhood health centers see fewer patients than expected, while big hospitals are crowded with patients suffering from minor maladies like colds.

To try to open up more “green” channels, the Tianlin clinic established a cooperative arrangement with Shanghai No. 6 People’s Hospital, a leading hospital in the same district. Under the plan, patients from the neighborhood health center can expeditiously see medical specialists at the hospital after being screened by their local GP, and patients released from the hospital can go to the health center for post-surgery care.

Patient information is sent by GP to the appropriate specialist, and the patient can bypass often-tedious hospital registration procedures.

The new system worked well for 67-year-old Hu Xiuying, who was sent to the No. 6 hospital for treatment of cardiovascular disease.

“I didn’t have to queue up in a long line to register at the hospital, and the treatment was efficient,” Hu said.

No benefit to hospitals

However, system expansion is limited by the reluctance of some hospitals to participate.

Dr Wang Lin, a GP at the Tianlin clinic, said big hospitals are passive in implementing the patient transfer system as they are busy and there is no benefit for them to do so.

“The government needs to take a more active role in pushing big hospitals to open green channels for GPs,” Wang said. “Moreover, a lack of information exchange can also hamper the system. It’s hard for us to follow the progress of patients we send to big hospitals.”



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