Health care as a family affair: Shanghai’s family doctor scheme is slow to gain acceptance
Shanghai's 'family doctor' scheme is slow to gain wide acceptance as an alternative to big hospitals
Tao Naiyu moved from his old apartment three months ago and has a community health centre adjacent to his new home. But he still rides his electric bike 20 minutes each way every two weeks to visit Zhoujiaqiao Community Health Centre in Shanghai's Changning District.
What makes the 79-year-old man do this is the service of his family doctor - Shanghai's answer to the UK's general practitioner. Tao said his doctor, Dr Chen Hua, had won his trust over the past two years and helped him as a relative would.
Tao usually picks up drugs at the Zhoujiaqiao clinic for his stomach cancer, hypertension and diabetes and occasionally gets check-ups with specialists. He said he was grateful that Chen suggested he undergo an examination to see if he had bladder cancer two years ago.
"Without my doctor's advice, I wouldn't have found that I had … cancer and my health would have deteriorated further," Tao said.
"My family doctor is so familiar with my health condition and what sicknesses I had before that I don't need to repeat my illness history like I do to other doctors," he said. "I feel assured with her service, and I don't have to worry about excessive drugs or check-ups."
Chen said she saw patients every morning in the clinic, mostly senior citizens with chronic diseases. In the afternoon she goes to residents' homes for check-ups or health education sessions. "As a family doctor, I have more time to chat with residents signed with me," she said. "I understand them more and thus can give more accurate medical advice."
Before the family doctor system came into existence three years ago, Tao, like most Shanghai residents, would first head to a big hospital whenever he was ill or injured. There, patients often have to endure hours of waiting because doctors see more than 100 of them a day and can only spend several minutes with each.
In order to relieve hospital crowding and the doctor-patient disputes it engenders, the Shanghai health authority was the first on the mainland to introduce the family doctor programme .
Under it, patients may choose between going to a hospital for their initial diagnosis, or visiting their regular family doctor.
According to the health authority, the family doctor system provides residents "trustworthy doctor friends" who assess people's health and create a unique "health management plan" for their patients. Those join the plan can also call a family doctors' hotline to seek free medical advice.
A patient's out-of-pocket costs for a visit to a family doctor at a community health centre come to less than 10 yuan (HK$12.50) in Shanghai. Medications or specialists cost additional fees, if necessary.
But despite the health authority's intentions, most often those who opt for the hospital instead of the community health clinic for initial diagnosis continue going to the big, renowned ones.
As a result, officials and medical experts said, Shanghai's family doctor system has not diverted as many patients as hoped.
"Our family doctor system has just made a start, and the ideal scenario hasn't been reached at all," said Liu Hongwei, director of the grass-roots health department in the Shanghai Commission of Health and Family Planning. "There is a long way to go."
Liu said a more rational use of medical resources would be to require people to consult family doctors first, then be transferred to small hospitals, and only referred to bigger ones when there was a dire need.
"We hope that family doctors can serve as the gatekeepers of public health and medical fees," he said.
About four million people, out of Shanghai's population of 24 million, have signed up with family doctors who are based in 170 community health centres, he said.
But fewer than 30 per cent of those residents routinely use their family doctors, said Dr Zhu Shanzhu, a leading family medicine expert who is affiliated with Shanghai's Zhongshan Hospital. Most choose to ignore their services and continue visiting big hospitals, Zhu said.
Another problem with the three-year-old medical plan is that some of Shanghai's family doctors underutilise their medical training, Zhu said, because they seldom practice as doctors but work mostly as a pharmacists and health educators.
Although they are called family doctors, they don't necessarily sign agreements with families, but rather with individuals, Zhu added.
In Tao's family, only he has a signed deal with a family doctor. His wife shrugged at the scheme, saying that her health was okay.
"Middle-aged or young people aren't [sold on] family doctors, because they don't trust the qualifications of these doctors at community-based hospitals or don't want to change their habit," Zhu said.
She said family doctors should, in theory, treat everyone, but too many community health clinics lack drugs specifically for children.
The Shanghai health authority has called on major hospitals to reserve some beds for patients referred to them by family doctors.
However, few big hospitals have done so because, in the words of one family doctor at Jingan Temple Street Hospital in Jingan District who spoke on condition of anonymity, they are "motivated by gaining profits" and are more interested in patients from outside Shanghai who are not covered by Shanghai's medical insurance scheme.
"In my opinion we family doctors don't have attractive resources for local residents and the public don't see any necessity to join the family doctor system," he said.
The doctor, who completed his schooling in 2007, said only one-third of his classmates in the three-year family medicine postgraduate training programme still worked in the field. Many have opted for higher-paying medical positions.
"If the government really thinks family doctors are important, they should dramatically raise our income. Now we earn merely 70,000 yuan a year, and how can we establish our own families in Shanghai?" the doctor said.
Liu said officials were aware of the income issue, but said "there is difficulty to persuade other departments to agree to [raise their] salaries".
Shanghai plans to equip all of its 240 community health centres with family doctors by the end of this year, and to require all of its residents to sign up with them by 2020.
Zhu is sceptical that this will improve the current situation, saying: "People can sign up, but they will possibly never use [them]."