In recent years, the policy has continuously increased the training of general practitioners, trying to use this as a breakthrough to strengthen grassroots strength and form the "first line of defense" for residents to seek medical treatment.
However, this series of favorable policies are aimed at public institutions such as community hospitals and community health service centers. Private clinics, which account for one third of primary health institutions, are not among them.
It's not hard to understand. As the only social medical institution in primary health institutions, the clinic is small in scale, large in quantity and flexible and convenient in service. Although the accessibility of medical services has been improved, it has also brought a series of regulatory problems. In the past few years, black clinics have been the key targets to crack down on illegal medical practice and rectify medical order.
In the current medical system with "public hospitals" as the main force, clinics are still extremely insignificant.
With the country's economic development entering the stage of high-quality development, medical reform has entered a critical moment, clinics have gradually entered the field of vision of decision-makers, and a series of favorable policies have been introduced in succession, hoping to promote the development of clinics. General clinics, in particular, are highly anticipated by some people-looking forward to guiding ordinary patients to adjust the pace of going to big hospitals through functional clinics all over the country, just like western countries.
In this process, there is always a "knot" about the positioning of the clinic. In China, individual clinics provide specialized medical services, and their access and approval are also in accordance with the standards of specialized clinics. "But primary health care often needs to solve comprehensive, diverse and regular health problems." Lu, the founder of Dr. Lu's community chain clinic in Chengdu, told the health department that the daily work of expert clinics, especially internal medicine clinics, is actually not much different from that of ordinary clinics.
There is a certain conflict between the orientation of specialty and the general function of clinic, which hinders the clinic from playing a greater role in graded diagnosis and treatment.
In recent years, the state is vigorously training general practitioners and encouraging them to set up general practice clinics. However, it takes ten years to grow trees and a hundred years to cultivate people. The cultivation of medical talents is far from a temporary achievement.
In this process, many experts and practitioners suggest that it is a more efficient way to promote the transformation of existing qualified and high-quality specialist clinics into general practice clinics and facilitate their practitioners to increase the scope of general practice.
The registration of clinics in China is mainly specialized, but it is mostly operated by general practitioners.
Giving full play to the "gatekeeper" role of primary medical institutions is a common practice for all countries, especially western developed countries, to control the rapid rise of medical expenses, realize patients' reasonable and orderly medical treatment and improve the efficiency of the overall medical and health service system.
"In western developed countries, more than half of the medical staff are general practitioners, and they undertake more than 50% of the medical service supply." Shen Zhiwei, who is in charge of clinic development in Honghua Medical, told the health department, especially the private general clinic founded by general practitioners, which occupies a dominant position in primary health care, providing not only basic diagnosis and treatment services, but also public health services such as planned immunization, health education and chronic disease management, solving most of the health needs of residents and building the "first line of defense" of medical services.
In Japan, large hospitals, especially university hospitals, do not accept patients who come directly to the hospital. Usually, they need to have their first visit in a private clinic. When they find it impossible to make diagnosis and treatment, they will make an appointment in advance and introduce patients to a big hospital.
In Singapore, private polyclinics provide 80% of basic medical outpatient services, and the remaining 20% are provided by public institutions. Compared with private general clinics, public general clinics are mainly aimed at low-income people and serve as referral points for graded diagnosis and treatment. Compared with private clinics, public general clinics have lower fees, longer waiting time, and are unable to choose their own doctors and expensive drugs.
In China, primary medical and health institutions include community health service centers, township hospitals, clinics and village clinics. Among these institutions, the first two, even village clinics in a strict sense, are all government-related institutions-only clinics belong to the society to run medical services.
By the end of June, 2020, the number of medical and health institutions in China exceeded 1 10,000, and there were 960,000 primary medical and health institutions, including 249,000 clinics, accounting for a quarter of the country and nearly a third of the grassroots, and the number increased year by year, making it a veritable medical service provider.
"Compared with government-run institutions such as community health service centers, clinics are market institutions organized by individuals. In order to survive and develop, operators must strengthen management, improve medical environment and improve service quality, such as opening for a longer time and providing more diversified services. At the same time, they should try their best to attract more patients. " Lu believes that it is small and exquisite, grounded, convenient and fast, and has certain privacy. , are the advantages of the clinic.
Lu resigned from the public hospital in 2005 and opened the first internal medicine clinic in Chengdu High-tech Zone. "At that time, I felt that many ordinary people went to the top three hospitals with a slight illness, and the cost was too high. If there is a reliable medical institution at home, it will be much easier. "
After more than ten years of development, Dr. Lu's community clinics have grown to 40 in Chengdu. Lu also believes that he has initially realized his "initial intention": the clinic not only provides residents with diagnosis and treatment services for common diseases and frequently-occurring diseases, but also helps residents interpret physical examination reports and popularize health knowledge, and gradually develops into a whole-process management platform for residents' health.
This is also the role and orientation that Lu Fengping thinks the clinic plays. She thinks this is no different from ordinary clinics in the west.
However, most clinics like Lu Fengping in China are registered as internal medicine clinics, not ordinary clinics, which also restricts them from providing general medical services to residents.
For a long time, the orientation of individual clinics in China is to provide specialized medical services, and the access and approval of individual clinics are also based on specialized clinics. Therefore, at present, most clinics only provide basic medical services in specific fields.
According to the investigation of 20 19, the top three disciplines in China clinic are internal medicine, surgery and stomatology. Because there was no general practice discipline in China in the early days, and only a few cities such as Shanghai and Guangzhou have set up general practice disciplines at present, the number of real registered general practice clinics in China is very small.
In practice, it is easy for specialist clinics to go beyond the scope of practice in the daily diagnosis and treatment process. For example, pediatric unregistered medical clinics accept children patients, and surgical unregistered medical clinics carry out emergency dressing. On the one hand, this may be a factor for clinics to consider interests, but it is more because primary medical services are extremely comprehensive and need to meet the diverse needs of the people.
"Clinics directly face the people and need to meet their various health needs." Lu told the health department that as long as the people trust a clinic, they will choose to come to the clinic for consultation if there is any disease, and they will not be divided into any subjects.
In her view, clinics, a primary medical institution with common diseases and frequently-occurring diseases as its main purpose, should naturally be "general practice", so as to truly solve people's problems. "Other clinics are the same, because if we can't provide diversified services to the people, patients will slowly lose."
Indeed, many clinics, especially internal medicine clinics, are actually playing the role of general clinics, especially in counties and townships, and some clinics even undertake some public health services. Huang Youxue, the community health service center of Fujian Dongqiao Economic Development Zone, wrote an article as early as 20 13, calling for the inclusion of individual clinics in the health management of chronic diseases in community health service centers to improve the health management level of chronic diseases.
Although the scope of practice of these institutions has not been "broken" at the policy level, from the functional point of view, it is completely consistent with the functions undertaken by general clinics in western countries.
It can be seen that there is a contradiction between the setting orientation of clinics based on specialties and the functional orientation of providing full-caliber, compound basic medical and health services in China, which is not conducive to the role of clinics in graded diagnosis and treatment.
Promote the transformation of existing specialist clinics into general clinics.
In order to improve the service ability of primary health care, the country is making great efforts to build a team of general practitioners, hoping to change the service model of primary health care through professional people and promote graded diagnosis and treatment.
The Guiding Opinions on Promoting the Construction of Graded Diagnosis and Treatment System issued in September, 2065438+2005 requires that general practitioners be trained through various channels, such as job transfer training for primary doctors, orientation training for general practitioners, and upgrading the educational level of primary doctors. 20 18 "opinions of the general office of the State Council on reforming and improving the incentive mechanism for training and using general practitioners" encourages general practitioners to set up individual clinics or partnership clinics independently.
However, there are still few general clinics in grass-roots institutions. On the one hand, the number of qualified general practitioners in China is small, on the other hand, it may be related to the specialty orientation of the clinic itself.
"Most of the general practitioners currently trained still flow to public hospitals, and there are still not many who really stay at the grassroots level." A medical administrator of a 3A hospital told the health department that general practitioners also need standardized training like other disciplines, but there is a fundamental contradiction in the training of general practitioners in public hospitals-3A hospitals rarely encounter common diseases and frequently-occurring diseases that need to be dealt with at the grassroots level, while the general practitioners trained by 3A hospitals still do not have the skills to work at the grassroots level.
For the current specialist clinics, if they want to provide general practice services, their practitioners must obtain a general practitioner certificate, and the prerequisite for obtaining the certificate is that they must undergo full-time standardized training in a large hospital for three years. "The practitioners in the clinic are struggling for survival every day, and there is no time and thought to spend so much time on this certificate." Ke Changde, the founder of the clinic, told the health community.
In this case, some experts and related practitioners suggest that the country urgently needs to rethink the positioning and classification of clinics, change the specialist positioning of clinics or guide existing specialist clinics, especially internal medicine clinics to transform into general practice. Only by opening this "door" can we revitalize a large number of existing private clinics, truly integrate private medical resources into the primary medical system and effectively transfuse blood.
The key is to stimulate the enthusiasm of the specialist clinic and try not to increase the workload of the clinic in this process. For example, we can choose a specialist clinic to carry out a pilot project, conduct general training through social training and distance training, encourage clinic practitioners to learn general knowledge after work, enrich the strength of general practitioners and clinics, and improve the level of primary medical services.
"At present, the development level of clinics in China presents a radish type of' two small heads and a big middle'-the number of particularly good and particularly poor is very small, and most of them are in the middle level." Ke Changde believes that the level of clinics is mixed or clinics are not valued by the government. Therefore, it is necessary to choose excellent clinics to carry out the pilot reform of general practice, especially those with high follow-up rate.
No matter what policy, strike while the iron is hot. "If the country can give us the status of a general clinic, we can provide more comprehensive and diverse services for the people aboveboard." Lu Fengping believes that no matter what the final positioning is, as a primary medical and health institution, the initial intention of continuously improving the medical level and striving to provide quality and convenient medical services for the people cannot be changed.