Drawing on International Experiences to Build General Practitioner System

Established in 1849， the Royal Dutch Medical Association seeks to promote the academic research and development in medical care to provide high-quality service. At the invitation of the CPAFFC， a 25-member RDMA delegation visited Beijing from March 15 to 20 for in-depth discussions on the general practitioner system with China’s National Health and Family Planning Commission， Beijing Municipal Health and Family Planning Commission， Peking University Health Science Center and Desheng Community Health Service Center.

Unlike specialist doctors in big hospitals， a GP works in primary-level medical institutions to provide basic services such as treatment of ordinary ailments and disease prevention. Since 1989， when the School of General Practice was set up in the Capital Medical University， the GP system has been gradually introduced to China. To improve the quality of grassroots medical services and enable people to have affordable medical care， the State Council issued guidelines on the establishment of the GP system in July 2012.

The target by 2020 is to provide every 10，000 urban and rural residents with access to two to three qualified general practitioners.

In the Netherlands， average life expectancy is 78 for men and 83 for women， while the infant mortality rate 4‰. Most of the country’s health indicators are higher than the United Kingdom and the United States. Total expenditure on medical care amounts to 11.9% of GDP， which is US$5，038 per capita， ranking the first on the Health Consumer Index of the European Union. Besides its strong economic foundations， the complete general practitioner system has also contributed to the country’s achievements in medical care.

According to Mr. Rene Heman， Vice President of the Royal Dutch Medical Association， the Netherlands has around 9，000 GPs， most of whom work in private clinics and provide direct medical services for community residents， being responsible for 85% of total medical needs and yet accounting for only 4% of the total cost of medical services.

The GP plays a vital role in meeting people’s needs for basic medical care， regulating the medical market and controlling medical costs.

From the exchanges between the delegation of the Royal Dutch Medical Association and relevant Chinese departments and institutions， there is an obvious gap in the general practitioner system and other areas between China and the developed countries that needs closing.

First is the positioning of general practitioners. By the definition of the World Organization of Family Doctors， they are supposed to provide comprehensive medical services to every person seeking medical care and when necessary， arrange for other medical professionals to provide relevant services outside their remit. In China， general practitioners are still regarded as community doctors， and community hospitals and clinics， which are large in number but with limited resources， keep them at the bottom of the pyramid. Due to various reasons including low pay and under-appreciation of their importance， it is hard for community hospitals to attract talents.

This could even lead to a vicious circle in which patients lose trust in community hospitals as they lack qualified professionals， and doctors working in community hospitals， who have few patients and feel undervalued， choose to change their career or seek to move to big hospitals.

A delegation member， Professor Pieter van den Hombergh of the University of Amsterdam， said the general practitioner is a very admirable job with a good social status in the Netherlands. For patients， he or she is usually the first point of contact when visiting a clinic almost like a doorkeeper. Most GPs are self-employed. Residents can choose to register with a GP who is paid by a medical fund based on the number of registered patients. An insured person can receive specialist treatment and compensation only through GP recommendation.

Second is the improvement of the medical insurance system. In China， because of an incomplete medical insurance system， patients lack easy access to affordable medical services on the one hand while hospitals operate in the red on the other. Big hospitals are able to strike a balance through large-scale market operation， but for community hospitals where most general practitioners work， it is difficult to make ends meet. This has resulted in low GP income which is about one-third of that of specialist doctors in big hospitals， and high charges for medical services.

Faced with similar high costs， patients prefer to see doctors in big hospitals even if it means long waiting time in queues rather than going to community hospitals. General practitioners thus fail to play the role of saving patients’ money and relieving big hospitals’ pressure.

According to Mr. Heman， medical funds and medical insurance companies will evaluate a GP according to surplus they get from of the premium. If the health conditions of the insured is not ideal in general， or the medical cost rises because of insufficient disease control， the medical fund and medical insurance company may terminate the contract and the general practitioner’s reputation will suffer. This leads to an emphasis on quality in the system.

Third is building trust between doctors and patients. The GP concept is introduced to China from abroad and there are misconceptions about the term. Patients often regard general practitioners as akin to the “barefoot doctors” of the past， while many others think that general practitioners， unlike specialist doctors， are capable of treating all kinds of diseases. Professionally trained general practitioners are insufficient in China at present as few universities run a suitable course. This has resulted in a number of problems including low professional education and rank， outdated knowledge structure and insufficient clinical experience. Thus， the GP cannot win patient trust in their professional expertise.

Professor Paul Mertens from Erasmus University in Rotterdam said general practitioners in the Netherlands had developed from the family doctor. Every resident needs to choose a general practitioner every year and pay certain amount of the cost for basic treatment. A GP needs a good background of medical education and practice including a three-year processional medical internship.

He or she studies the patient’s record and current condition to decide if treatment is possible， or whether referral to a specialist doctor for further diagnosis and treatment may be justified. A long-term service relationship， rich practical experience and comprehensive knowledge structure have formed the foundation of trust between doctors and patients.

As the saying goes， “Advice from others may help one overcome one’s short-comings”. By learning the experience of developed countries including the Netherlands and improving its general practitioner system， China may find the cure for the lack of medical resources.

Through receiving this delegation， we have seen the role of international professional organizations in providing intelligence support and advice for reform and development of relevant fields in China. The CPAFFC can contribute more to the country’s social and economic development by bringing into full play its advantages in this regard.