People visiting Shanghai's top hospitals are often frustrated by the cramped and crowded conditions they encounter. But even though they look more like busy wet markets, bustling with hundreds of customers, than elite medical institutions, efforts by the municipal authorities to stem the tide of patients and make medical care more convenient have met with overwhelming public opposition. In a five-year reform blueprint for the city's health-care sector announced recently, Shanghai introduced the concept of 'medical institute alliances'. Two pilot schemes were set up, one in Luwan district in January and the second in Chongming district in April. Residents in the two districts can choose to join special health care schemes provided by the alliances - a network comprising one or two Class-A hospitals, some smaller Class-B hospitals and many community hospitals. A resident who joins the scheme will first have their illness diagnosed at a community hospital. If their condition does not improve, they will then be transferred to a Class-B hospital. If they're still not cured, they will be transferred to the Class-A hospital. If that fails, the network will contact other hospitals, outside the alliance, for help. Mainland hospitals are generally split into three classes: the highest level, Class-A hospitals, with more than 500 beds that are also engaged in higher education and medical research; Class-B hospitals with 101 to 500 beds, that serve several communities; and Class-C or community hospitals, with fewer than 100 beds, that cater to residents of a single neighbourhood. Shanghai said in March that it planned to form 15 such alliances. Officials tout many benefits to lure residents to join, saying that people will have their own health dossier, be given priority when transferring between hospitals, will find it easier to make appointments with doctors at Class-A hospitals and will be able to avoid multiple check-ups because the results from different clinics will be shared. Senior doctors from Class-A hospitals will spend some time each week working in grass-roots wards, while community medical staff will be sent to higher-ranking hospitals to hone their skills. However, the scheme is proving to be a hard sell, with a survey by Shanghai's Statistics Bureau early this month finding that public opposition is running at 70 per cent. At present, people can go to any public hospital in Shanghai for treatment and be covered by the city's medical insurance scheme. One third of survey respondents said they went straight to a Class-A clinic if they fell ill. About half said they were concerned about the professionalism of community medics, while roughly one-eighth thought Class-C hospital facilities were shabby and lacked access to some drugs. Nearly half were concerned that they would be deprived of the right to select the hospital where they would be treated. And a quarter were worried that being transferred between alliance hospitals, rather than going directly to the best specialist they could find in the city, would delay effective treatment. Some people also thought the new system gave community medical staff too much authority. Ironically, a similar system existed in the 1990s, when people were asked to designate several hospitals to be linked to their medical insurance account, with the cost of treatment at those hospitals written off. But Professor Liu Bao, a public health expert from Fudan University, says Shanghai abandoned that policy in 2000 due to complaints that it restricted personal choice. Ever since, people have been able to use their insurance cards at any clinic. Such unlimited freedom has seen many people opt for treatment at Class-A hospitals. Local media have reported that half of Class-A clinics' outpatients are there for minor ailments like colds or coughs or for already diagnosed chronic diseases, such as diabetes. There are fewer than 40 Class-A hospitals in Shanghai, accounting for just 3 per cent of the city's medical institutions. But they receive tens of thousands of loyal patients every day, half of whom are from outside Shanghai, according to the Wen Hui Bao newspaper. It's no wonder that a doctor at a Class-A hospital routinely sees dozens, if not scores, of outpatients a day. And patients are suffering from hours and hours of queuing at each stage of the process - registering for a doctor, the consultation, paying for drugs and examinations, collecting drugs and returning for check-ups and follow-up consultations. Many inpatients have to wait for weeks or months before being admitted for treatment. A key component of the nationwide medical reform that began two years ago was to direct patients with minor ailments to community clinics and away from big hospitals, but the campaign was poorly received due to a lack of confidence in community-level medical practitioners. In Shanghai, a series of incentives have been provided, including raising the reimbursement level at community clinics, but they have not worked very well. Liu said it was hard to change people's long-held preferences in such a short period. Professor Ma Jin, dean of the school of public health at Shanghai Jiaotong University, said there was an urgent need to promote community medicine, already adopted by many Western countries, as it was the best cure for Shanghai and the mainland's poor access to medical resources. 'People should be educated that doctors at Class-A health centres may be known for their skills, but they're not familiar with you. And a two-minute consultation won't always result in the correct diagnosis,' Ma said. 'But community doctors know you well - they're like your friends. So this obsession with elite hospitals and their staff is unnecessary.' Shanghai is also introducing family doctors - similar to Hong Kong's system of general practitioners - to relieve the burden on top hospitals. It's a novel concept for mainlanders, with only around 5,000 GPs across the country. Most leading medical schools do not even set aside a major for GPs. They only train specialists, and the subject of general practice was only introduced in the past few years. According to Shanghai's ambitious plan, 8,000 GPs will be needed to cover its 23 million residents by 2015. Most will be existing community medical staff who will have to undertake months of on-the-job training. Experts said their medical skills would remain questionable and that meant they would be unable to win the public's trust in the short term. So expect those crowds at top hospitals for a few more years.