GP based primary care is only just starting to emerge in China

If China used GPs instead of hospitals to deliver primary health care, one in five deaths that are due to preventable risk factors could potentially be averted, say researchers at the University of Sydney.

Such a system would also help to get the best results from China’s ¥850bn (£81bn; €98bn; $125bn) health reform package now under way, but there are few signs that the idea is being embraced, observers say.

Hypertension accounts for 11.7% of deaths in China, while smoking and physical inactivity account for 7.9% and 6.8%, respectively. “Primary care is better placed than large hospitals to monitor risk factors such as high blood pressure, smoking, diet, exercise, and other lifestyle changes,” said Lyndal Trevena, head of the Office for Global Health at Sydney Medical School. “Many of the most effective strategies to address these risk factors can be implemented in primary care.”

Professor Trevena was speaking to the BMJ from Shanghai, where she was taking part in a symposium on translational medicine as part of the Shanghai Expo. She said that currently most patients in China seek care by going to a hospital, and the hospital sector employs 61% of all healthcare workers. The concept of general practice medicine has not been widely accepted. Even where GP based clinics do exist they are still not necessarily the first port of call, and doctors do not act as gatekeepers for hospital care.

“The typical GP set-up is a community health centre, with six or seven small subclinics employing approximately 50 GPs and 50 nurses,” said Professor Trevena, who has been collaborating with academics in the general practice department of Fudan University’s Zhongshan Hospital in Shanghai to promote the concept of GP led care in China.

She said, “There is a wonderful integration of Chinese and Western medicine [in the health centres], and they manage mostly chronic disease such as hypertension, diabetes, and chronic heart disease. However, it seems that a lot of parents still take their children straight to paediatric hospitals when they are sick.”

The Shanghai GPs were eager to hear about the concepts of the “whole patient” approach and continuity of care. “They were very interested in asking about referral pathways and the GP interface with hospitals, but they were not familiar with the concept of the GP as a gatekeeper,” she said.

Widespread introduction of GPs or rural community clinics could help China achieve one of its main health reform objectives of improving primary care and would ensure that the extra money being pumped into health care gets results, particularly if the financing mechanism can be used to create a gatekeeper system, said Henk Bekedam, director of health sector development at the World Health Organization’s Western Pacific regional office in Manila.

China is working towards universal coverage of care through social insurance schemes, but healthcare providers still rely heavily on copayments and out of pocket expenditure on a fee for service basis. “The financial commitment is there,” said Dr Bekedam, “but China still has a major challenge in getting value for that money. One way is to focus on financial protection and increase reimbursement levels, but if you don’t change from user fees what you often see is that the money goes too quickly into the pockets of the providers.

“That extra money needs to be used to strengthen purchasing power; and while you are putting extra money on the table, that’s a good time to start changing the way providers are paid.”

Currently the payment system is often the main obstacle to developing GP led primary care, said Jui-fen Rachel Lu, professor and dean of the Department of Health Care Management at Chang Gung University, Taiwan. “Doctors are making good money for treating patients but not keeping them healthy. The incentives inherent in the payment system often discourage the promotion of GP led primary care,” she said.

She added: “I don’t think China’s current reform emphasises the value of GP led primary care. In the urban areas resources are still mainly devoted to vast investment in major hospitals which house expensive modern technology. In the rural areas there are hardly any formally trained doctors—village doctors (“barefoot doctors”) are the main primary care providers, but this is far from what you call GP based primary care.”