Shanghai’s Community Hospitals Offer Model for Tiered Medical Treatment (AI Translation)
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文｜财新周刊 许雯 赵今朝
By Caixin Weekly's Xu Wen and Zhao Jinzhao
2023年至今，一套自上而下的强基层“组合拳”正在上海推开，旨在提升社区医疗服务能力。
Since 2023, a comprehensive top-down initiative aimed at strengthening primary care services has been rolled out in Shanghai, with the goal of enhancing community healthcare capabilities.
作为卫生健康服务体系的网底，在新冠疫情期间，上海社区发热门诊承担了超过60%的工作量，有效分流二三级医疗机构的就诊压力。作为医疗体系的“神经末梢”，社区医疗的重要性再度得到现实验证，诊疗能力不足、设备药品短缺的痼疾也在其间暴露无遗。由此，发展社区医疗成为疫情后上海卫生系统的工作重点之一。
As the foundational layer of the healthcare service system, community fever clinics in Shanghai bore more than 60% of the workload during the COVID-19 pandemic, effectively alleviating the patient burden on secondary and tertiary medical institutions. The pandemic once again underscored the critical role of community healthcare as the "nerve endings" of the medical system. However, it also laid bare chronic issues such as inadequate treatment capabilities and shortages of equipment and medicines. Consequently, the development of community healthcare has become one of the primary focuses for Shanghai's health system in the post-pandemic era.
2023年4月，上海印发《进一步提升本市社区卫生服务能力的实施方案》（下称《实施方案》）。这份“红头文件”由上海市人民政府办公厅出台，各区政府、卫健委、医保局、财政局、民政局各有分工。因直击“挂号难”的痛点，“号源下放”成为最受关注的举措，另有硬件升级、增加检查检验设备、药品扩容、病种扩充、鼓励手术等措施，从硬件到政策，勾勒上海基层医疗体系发展蓝图。
In April 2023, Shanghai issued the "Implementation Plan to Further Enhance Community Health Service Capacity in the Municipality" (hereinafter referred to as the "Implementation Plan"). This official document was released by the General Office of the Shanghai Municipal People's Government and involves the cooperation of district governments, health commissions, medical insurance bureaus, finance bureaus, and civil affairs bureaus. In addressing the pressing issue of "difficulties in obtaining registration for medical appointments," the most noteworthy initiative is the decentralization of appointment slots. Additionally, there are measures for hardware upgrades, an increase in diagnostic and testing equipment, expansion of pharmaceutical offerings, broadening the range of treatable diseases, and encouraging surgeries. Together, these measures from hardware improvements to policy initiatives outline the development blueprint for Shanghai's grassroots medical system.
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- Shanghai has implemented a comprehensive plan to improve primary care by enhancing community health services, including hardware upgrades, increasing diagnostic capabilities, expanding drug availability, and redistributing appointment slots.
- Initial results show a 17.9% increase in outpatient visits at community health service institutions, yet these visits account for less than 40% of total outpatient visits, highlighting ongoing challenges in achieving a tiered treatment system.
- Despite improvements, issues such as hardware shortages, inadequate treatment capabilities, and reluctance from large hospitals to transfer patients persist, marking hurdles to the success of the reforms.
Since 2023, a significant initiative has been launched in Shanghai to enhance primary care services, particularly focusing on community healthcare. This effort aims to address chronic issues such as inadequate treatment capabilities and shortages of equipment and medications that were highlighted during the COVID-19 pandemic [para. 1][para. 2]. The primary vehicle for these changes is the "Implementation Plan to Further Enhance Community Health Service Capacity in the Municipality," issued in April 2023. This plan involves collaboration among various governmental departments and focuses on decentralizing appointment slots, upgrading hardware, expanding pharmaceutical offerings, and encouraging surgeries at the community level [para. 3].
The primary objective is to establish a tiered diagnosis and treatment system, where minor illnesses are treated at the grassroots level while serious conditions are referred to higher-level hospitals. This approach aims to change the perception that community healthcare is limited and to enhance the overall medical experience for residents [para. 4][para. 5]. Historically, hierarchical medical treatment in China has faced challenges, with more resources being funneled into large hospitals while primary healthcare struggles to keep up [para. 6][para. 7].
The policy has shown initial positive effects, with an increase in outpatient visits at community health service institutions by over 5 million year-on-year, although this still represents less than 40% of the city's total outpatient visits [para. 3]. Measures like the prioritized availability of expert appointments at community health service centers have been implemented to attract more patients. This approach has significantly increased the number of appointments secured at top-tier hospitals through community centers [para. 9][para. 13].
Despite these improvements, some community health centers still face challenges such as insufficient facilities, outdated equipment, a lack of medical professionals, and limited drug availability [para. 27][para. 28][para. 31]. The Shanghai government has been working on upgrading community healthcare infrastructure, expanding drug lists, and providing additional training for community doctors to address these issues and improve diagnostic and treatment capabilities [para. 60][para. 63][para. 64]. The inclusion of new equipment during the pandemic has continued to play a significant role in managing current healthcare demands [para. 47][para. 48].
However, the initiative's success has been mixed. Some residents still prefer higher-level hospitals due to distrust in community healthcare services, and large hospitals may be reluctant to decentralize patients. This situation is compounded by payment reform systems like DRG, which may disincentivize large hospitals from delegating patients to lower-level institutions [para. 82][para. 84].
To create a more effective tiered medical system, experts call for significant structural changes. For instance, in Shenzhen, the integration of public medical resources and the establishment of a community of shared interests among different healthcare levels has shown promising results. This model allows doctors to move within the group, benefiting patients and reducing the overall burden on the healthcare system [para. 90]. In Shanghai, despite some progress, comprehensive reform is needed to create a coherent system that centers around patient needs rather than hospital profitability [para. 92][para. 93][para. 94].
- Huashan Hospital
华山医院 - Huashan Hospital, located in Shanghai, played a key role during the pandemic. A new policy since April 2023 has aimed to alleviate appointment difficulties by allocating 50% of its appointment slots to community health centers. The hospital’s doctors, such as neurologist Dr. Wang Liang, now provide services at these centers, improving accessibility for residents.
- Huashan Hospital Affiliated to Fudan University
复旦大学附属华山医院 - Huashan Hospital Affiliated to Fudan University is a prominent medical institution in Shanghai. It played a crucial role during the COVID-19 pandemic, with significant patient treatment contributions. As part of the city's healthcare reforms, Huashan Hospital provides expert consultations, which are now accessible through community health centers. This initiative helps alleviate the challenges of getting appointments, enhancing the integration of healthcare resources.
- Xinhua Street Community Health Service Center of Changning District, Shanghai
上海长宁区新华街道社区卫生服务中心 - At Xinhua Street Community Health Service Center in Changning District, Shanghai, resident Chen, with hypertension and a history of cerebral infarction, successfully booked an expert appointment with neurologist Wang Liang of Huashan Hospital through her family doctor, Zhang Li. The center utilizes the new policy of descending appointment slots to provide better access to specialists for its residents.
- Xinzhuang Community Health Service Center of Minhang District
闵行区莘庄社区卫生服务中心 - Xinzhuang Community Health Service Center in Minhang District is undergoing improvements to its infrastructure and services. It has installed new CT equipment, is planning a small surgery room, and has seen increased patient referrals due to the new "source availability" policy. The center ranks high in referral numbers, indicating strong patient and doctor engagement.
- Renji Hospital
仁济医院 - Renji Hospital is mentioned as a preferred choice for transferring patients with ulcerative colitis from the community healthcare system in Shanghai. The hospital is known for its specialized care in digestive diseases, making it a top referral destination within the city's structured medical network working towards enhancing community-level healthcare services.
- Zhongshan Hospital
中山医院 - According to the article, Zhongshan Hospital is one of the priority referral hospitals for cardiovascular diseases under the new community healthcare initiatives in Shanghai. It is among the preferred upper-level hospitals alongside other major institutions like Huashan Hospital and Ruijin Hospital.
- Ruijin Hospital
瑞金医院 - Ruijin Hospital, mentioned in the context of Shanghai's community medical reforms, is one of the top-ranked hospitals referred to for advanced medical treatments. As part of the policy for patient management, high-priority diseases, especially cardiovascular issues, are recommended to be transferred to Ruijin Hospital for further treatment, highlighting its integral role in Shanghai's healthcare ecosystem.
- Shanghai Sixth People's Hospital
上海六院 - Shanghai Sixth People's Hospital is listed as one of the preferred hospitals for patient referrals in the article. It is one of the city-level tertiary hospitals involved in Shanghai's initiative to strengthen community healthcare by providing expert consultations and specialized medical support to local healthcare centers.
- Longhua Hospital
龙华医院 - Longhua Hospital is one of the hospitals in Shanghai to which community health service centers frequently refer patients. It is a city-level tertiary hospital and was mentioned alongside others like Zhongshan Hospital and Ruijin Hospital for being a key referral destination in the city's healthcare network.
- Since 2023：
- A comprehensive top-down initiative aimed at strengthening primary care services has been rolled out in Shanghai.
- April 2023：
- Shanghai issued the "Implementation Plan to Further Enhance Community Health Service Capacity in the Municipality."
- April 12, 2024：
- The policy to release appointment slots allowing community health service centers to offer appointments with municipal and district hospitals was implemented.
- By mid-2024：
- The number of outpatient visits at community health service institutions in Shanghai increased by more than 5 million year-on-year, a rise of over 17%.
- June 17th, 2024：
- Mrs. Chen secured a specialist appointment with Wang Liang at Huashan Hospital through her family doctor Zhang Li as part of the new appointment allocation policy.
- By September 15, 2024：
- The Minhang District had 16,978 cumulative appointment slots since the policy's implementation, with Xinzhuang community topping the list.
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