Ten-year development of general practice in China: Opportunities and challenges

Abstract

Objective: To review the strengths and limitations of the development of general practice in China during the last decade (2010—2020) and to assess the opportunities and challenges for its future development.

Methods: Data were collected from statistic reports, journal articles and official policies and guidelines regarding general practice development in China from 2010 to 2020. Donabedian model was applied to examine and assess the quality of general practice services in China. SWOT analysis was used to identify internal and external determinants of general practice development in China.

Results: (1) Structural quality of general practice:the ten-year policies about general practice development were a continuation of the past relevant policies in essence but with developments, with highlights on continuous construction of general practice workforce and discipline, tiered diagnosis and treatment and regional medical consortium, but relevant fiscal and management policies still need improvements. The number of general practice workforce has increased rapidly, while the lion share of them are still allocated at tertiary hospitals. Full-time equivalent is suggested to be used to predict the staffing and assess the performance of general practice professionals. The number of community health centres showed a steady increase, but its growth rate was still slower than that of hospital facilities. Relevant health economics data need to be further supplemented. (2) Process quality of general practice:in 2020, there were 2.045 billion visits in community health centers (stations) and township health centers, that is, 1.5 visits per person per year on average. There was a significant development when found only 1 visit per person per year for primary care in 2010. However, the frequency of visits for primary care was still lower than that of visiting hospital-based outpatients (an average of 2.7 visits per person per year). The COVID-19 pandemic had a significant impact on community health services/general practices, and the number of outpatient visits dropped by about 20%. The number of general practice research articles reached a peak in 2018, mainly focusing on dual-directional referrals, tiered diagnosis and treatment, general practitioners (GPs) /family doctors, general medicine, community health services, chronic disease management (especially hypertension and diabetes), and analysis of factors associated with aspects involved in general practices. General practice research is expected to provide more support for developing innovative and critical thoughts, more practice based evidence for clinical services, and more assistance for service quality and patient outcomes improvement as the discipline advances. (3) Results of implementing general practices:there is no sufficient evidence on the influence of general practices on people's health. The experiences and views of people including healthy individuals and patients indicated that those receiving general practices or contracted family doctor services perceived positive experience and expressed high satisfaction, but perceptions and views of general population in the community toward general practices need to be explored. GPs' own experience and opinions on general practice were quite different. Gender, age, professional title, urban and rural areas, and geographical location may be associated with their experience and job satisfaction. There may be instability in the general practice workforce, mainly due to personal income, workload and time pressure. (4) The major strengths of developing general practice in China are as follows:strong policy-based promotion and government leadership;rapidly constructing and developing GPs teams owing to the excellent resource allocating ability shown by the centralized system from central to all local governments;significantly enhanced general practice education and training systems;increased core professionals as general practice educators and trainers;special development of general practice characterized by the integration of medical sciences and Chinese traditional humanistic theories. (5) The development of general practice in China has been facing limitations similar to those in other countries. Besides that, its evident limitations include late development of the discipline, unsatisfactory quality of workforce, high work pressure and high prevalence of burnout in the workforce, as well as impact of generation gap on education and practice among GPs. In addition, the relation between specialists and GPs is on transition of from undifferentiated attachment to self-recognised uniquity, and further seeking transdisciplinary. The teaching competences of GPs teachers, especially those teaching community and clinical care, are inadequate. GPs team building and management need to advance from the formation to the storming and performing phases. (6) Opportunities for further development of general practice in China include strategies for achieving the goals of Healthy China, and an all-round well-off society, the important role of primary health care in sustainable development and universal health coverage reaffirmed by the Declaration of Astana, as well as significantly improved health literacy of people. (7) Challenges for the development of general practice in China include population ageing, and aging-related changes in burden of disease and socio-economic status, the aging and dynamic changes of GPs human resources, the variation of urban and rural areas and regional differences, and the inverted pyramid structure of allocation of medical and health resources (namely, the largest part is allocated to tertiary care while the smallest to primary care). Relevant recommendations to address these challenges comprise strengthening the advocacy of the development of general practice services, establishing a wide-ranging community collaborative network, and developing general practice professional organizations.

Conclusion: The development of general practice in China is advancing, which is manifested as rapidly increased number of general practitioners(GPs), strong government promotion, quickly improved accessibility of essential medical services, and notably increased utilization rate of primary care services. However, the development is facing challenges, such as high discipline and social expectations regarding general practice, instability in the workforce due to high work pressure of the knowledge- and labor-intensive job, GPs' insufficient recognition of their self-identity, and unclear status of financial funding for general practice development. Given that there are unprecedented favorable conditions for general practice development, medical industries and GPs are suggested to make efforts to turn challenges into opportunities to develop general practice, thereby universal health outcomes will be improved.

Keywords

General practice / General practitioners / Industry report / Outcome and process assessment / Health care / Health policy / Health manpower / Health expenditure

Declarations

Not applicable.

Ethical approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and materials

Not applicable.

Funding

Not applicable.

CRediT authorship contribution statement

Yang Hui: Conceptualization, Formal analysis, Funding acquisition, Project administration, Resources, Supervision, Validation, Writing - original draft, Writing - review & editing. Han Jianjun: Conceptualization, Writing - review & editing. Xu Yanli: Conceptualization, Writing - review & editing. Gao Xiaohuan: Methodology, Data curation. Wang Yang: Writing - review & editing. Yang Yunli: Methodology, Data curation. Cao Xinyang: Methodology, Data curation.

Declaration of competing interest

Y.H. and W.Y. are the editorial members of Chinese General Practice Journal, X.Y. and C.X. are editors of Chinese General Practice Journal, they are not envolved in the editorial review or the decision to publish this article. All authors declare that there are no competing interests.

Acknowledgements

Not applicable.

References

[1] Starfield B. Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. Gac Sanit. 2012; 26(Suppl 1):20-26. doi: 10.1016/j.gaceta.2011.10.009.

[2] Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q. 2005; 83(4):691-729. doi: 10.1111/j.1468-0009.2005.00397.x.

[3] Zhang GS. Analysis and forecasting on the demand for health human resources in China. Chinese. Chin J Health Policy. 2011; 4(12):1-5. doi: 10.3969/j.issn.1674-2982.2011.12.001.

[4] Ministry of Health. Medium- and long-term talent development plan for medicine and health (2011-2020) [Internet]. (Chinese). 2011 [cited 2021 Oct 1]. Available from: http://www.gov.cn/zwgk/2011-04/28/content_1854246.htm.

[5] National Health Commission of the People’s Republic of China. (Chinese). China Health Statistics Yearbook 2021. Beijing: Peking Union Medical College Press; 2021.

[6] National Health Commission of the People’s Republic of China. China health statistics yearbook (2011-2019) [Internet]. (Chinese). [cited 2021 Oct 1]. Available from: http://www.nhc.gov.cn/mohwsbwstjxxzx/tjzxtjsj/tjsj_list.shtml.

[7] National Health Commission of the People’s Republic of China. (Chinese). China Health Statistics Yearbook 2020. Beijing: Peking Union Medical College Press; 2021.

[8] Australian Institute of Health and Welfare (AIHW). Health expenditure Australia 2003-04 [Internet]. 2005 [cited 2021 Oct 1]. Available from: http://www.aihw.gov.au/publications/index.cfm/title/10204.

[9] Chen X, Liu M, Liu CJ, et al. Job satisfaction and hospital performance rated by physicians in China: a moderated mediation analysis on the role of income and person-organization fit. Int J Environ Res Public Health. 2020; 17(16):5846. doi: 10.3390/ijerph17165846.

[10] Richardson J, Walsh J, Pegram R. Government Department of Health and Ageing Canberra. General practice in Australia: 2004. Financing general practice, health services and expenditures. Canberra: Government Department of Health and Ageing Canberra; 2005.

[11] Ruse WH. The decline in bulk-billing and increase in out-of-pocket costs for general practice consultations in rural areas of Australia, 1995-2001. Med J Aust. 2003; 178(9):470-471. doi: 10.5694/j.1326-5377.2003.tb05298.x.

[12] Shenzhen Municipal Health Commission. 2020 Shenzhen health statistics summary [Internet]. (Chinese). 2021 [cited 2021 Oct 1]. Available from: http://wjw.sz.gov.cn/jksz/sjjd/content/post_9049884.html.

[13] Qin JM, Wang F, Lin CM, et al. Recent developments in performance assessment policies and practices in primary healthcare in China. (Chinese). Chin Gen Pract. 2021; 24(16):1989-1994. doi: 10.12114/j.issn.1007-9572.2021.00.194.

[14] Yu DH, Wang ZX, Lu Y, et al. Evaluation and prospect of scientific research capacity of community health service centers in China (2019). (Chinese). Chin Gen Pract. 2019; 22(28):3406-3410. doi: 10.12114/j.issn.1007-9572.2019.00.511.

[15] Cockerham W. Medical Sociology. (Chinese). Beijing: Huaxia Publishing House; 2000 Yang H, Zhang TH, translators.

[16] Zhang YJ, Yin WQ, Yan Y, et al. Residents’ satisfaction with family doctors contract services in China: a meta-analysis. (Chinese). Chin J Evid Based Med. 2021; 21(10):1148-1153. doi: 10.7507/1672-2531.202106177.

[17] Han XR, Qin CX, Wu Y, et al. Accessibility and comprehensiveness of contracted family doctor services in rural areas using perceived quality framework. (Chinese). Chin Gen Pract. 2021; 24(19):2428-2434. doi: 10.12114/j.issn.1007-9572.2021.00.181.

[18] Liu TX, Hao Y, Cui YQ, et al. Perception, utilization and satisfaction regarding bi-directional referral services in young and middle-aged white-collar workers working in office buildings. Chinese. Chin Gen Pract. 2021; 24(16):2044-2050. doi: 10.12114/j.issn.1007-9572.2021.00.048.

[19] Yin D, Zhang JR, Wang Z, et al. Delivery status of contractual services from family doctors in China and advances in the related studies. (Chinese). Chin Gen Pract. 2018; 21(7):753-760. doi: 10.3969/j.issn.1007-9572.2018.07.001.

[20] Hou H, Dai RH, Wu J, et al. Professional identity of family doctor team members and influencing factors: a survey. Chinese. Chin Gen Pract. 2021; 24(19):2445-2451 2458. doi: 10.12114/j.issn.1007-9572.2021.00.211.

[21] Feng J, Shen X, Wu JX, et al. Status quo and influencing factors of professional identity among general practitioners in China. Chinese. Med Soc. 2021; 34(10):13-16. doi: 10.13723/j.yxysh.2021.10.002.

[22] Chen DM, Ren WC, Wang YJ, et al. Surveying the satisfaction degree of general practitioners in Henan Province. Chinese. Chin Health Serv Manag. 2021; 38(3):212-215.

[23] Liu JL, Feng G, Du ZQ, et al. Study on the current status of talents team career development and the influencing factors of career development satisfaction of township health centers in Western China. (Chinese). China Med Herald. 2021; 18(12):74-77 89.

[24] Liu CY, He TT, Wang Q. Responses to the supportive policies for the implementation of contracted family doctor services and job satisfaction in primary healthcare workers. Chinese. Chin Gen Pract. 2019; 22(10):1160-1164. doi: 10.12114/j.issn.1007-9572.2019.10.006.

[25] Feng J, Shen X, Gan Y. Turnover Intention and its Influencing Factors Among General Practitioners in the Eastern, Central and Western China [Internet]. (Chinese). Chin J Public Health; 2021 citedAvailable from: https://kns.cnki.net/kcms/detail/21.1234.R.20210814.1834.014.html.

[26] Liu MX, Ding J, Ji Y, et al. Burnout prevalence and associated factors among family doctors in Xicheng District of Beijing. (Chinese). Chin Gen Pract. 2021; 24(13):1656-1664. doi: 10.12114/j.issn.1007-9572.2020.00.537.

[27] Schattner P, Mazalin D, Pier C, et al. GP registrar well-being: a cross-sectional survey. Asia Pac Fam Med. 2010; 9(1):2. doi: 10.1186/1447-056X-9-2.

[28] Schattner PL, Coman GJ. The stress of metropolitan general practice. Med J Aust. 1998; 169(3):133-137. doi: 10.5694/j.1326-5377.1998.tb116013.x.

[29] Egger G, Katz D, Sagner M, et al. The art and science of chronic disease management come together in a lifestyle-focused approach to primary care. Int J Clin Pract. 2014; 68(12):1406-1409. doi: 10.1111/ijcp.12500.

[30] Murtagh J, Rosenblatt J. John Murtagh’s General Practice. 7th ed. Melbourne: McGraw Hill; 2018.

[31] Pollard L, Rogers S, Shribman J, et al. A study of role expansion: a new GP role in cardiology care. BMC Health Serv Res. 2014; 14(1):205. doi: 10.1186/1472-6963-14-205.

[32] Ross S, Gillies JC. Characteristics and career intentions of Scottish rural and urban GP registrars: cause for concern. Health Bull. 1999; 57(1):44-52.

[33] Ying MK, Liu Y, Ren JJ. The specialists’ views on general practitioners with special interests. Chinese. Chin Gen Pract. 2019; 22(16):1936-1939. doi: 10.12114/j.issn.1007-9572.2019.00.288.

[34] Liu Y, Chen SH, Qiu Y, et al. GPs with special interests training in China and relevant recommendations. (Chinese). Chin Gen Pract. 2018; 21(22):2664-2667. doi: 10.12114/j.issn.1007-9572.2018.22.004.

[35] Trumble S. Being a specialist GP. Aust Fam Phys. 2005; 34(1-2):5.

[36] Trumble S. The GP as a teacher. Med J Aust. 1991; 155(5):322-324.

[37] Thomson JS, Anderson K, Haesler E, et al. The learner’s perspective in GP teaching practices with multi-level learners: a qualitative study. BMC Med Educ. 2014; 14(1):55. doi: 10.1186/1472-6920-14-55.

[38] Natvig D, Stark NL. A project team analysis using Tuckman’s model of small-group development. J Nurs Educ. 2016; 55(12):675-681. doi: 10.3928/01484834-20161114-03.

[39] Central Committee of the Communist Party of China, State Council. Outline of “Healthy China 2030 ” plan [Internet]. (Chinese). 2016 [cited 2021 Oct 1]. Available from: http://www.nhc.gov.cn/guihuaxxs/s3586s/201610/21d120c917284007ad9c7aa8e9634bb4.shtml.

[40] Yang H, Chen YD. The Astana Declaration and preventive medicine in China. Chinese. Chin J Prev Med. 2019; 53(2):136-140. doi: 10.3760/cma.j.issn.0253-9624.2019.02.003.

[41] Shi J, Jin H, Shi L, et al. The quality of primary care in community health centers: comparison among urban, suburban and rural users in Shanghai, China. BMC Fam Pract. 2020; 21(1):178-192. doi: 10.21203/rs.3.rs-28943/v2.

[42] Leiyu S. Health care in China: a rural-urban comparison after the socioeconomic reforms. Bull World Health Organ. 1993; 71(6):723-736.

[43] Xu S, Dong X, Zhou R, et al. Health service utilization following symptomatic respiratory tract infections and influencing factors among urban and rural residents in Anhui. China. Prim Health Care Res Dev.. 2019; 20:e150. doi: 10.1017/S1463423619000896.

[44] Blayney DW. Strengths, weaknesses, opportunities, and threats. J Oncol Pract. 2008; 4(2):53. doi: 10.1200/JOP.0820501.

[45] Trumble S. Advocacy, guardianship and the GP. Aust Fam Phys. 1993; 22(2):188-191194.