The developing family doctor system: evidence from the progress of the family doctor signing service from a longitudinal survey (2013–2016) in Pudong New Area, Shanghai

Changes in medical modes and population aging resulted in a “blowout” of chronic diseases. The long-term survival of patients with chronic diseases requires good treatment, continuity of services, comprehensive community interventions, and personalized services. Furthermore, with the increasingly specialized and refined development of medical technology, a mismatch emerged between “high health demand” and “high service technology.” In reality, many patients experience difficulty finding corresponding medical service technology, meaning many cases require emergency treatment.

In China, promoting family doctor contracting services was a key breakthrough in implementing a graded diagnosis and treatment system. Through the family doctor contract service system, family doctors provide comprehensive services to help patients who lack professional knowledge to improve their ability to appropriately choose medical institutions and obtain long-term coordinated healthcare. To date, over 50 countries and regions have implemented a family doctor system, including the United Kingdom, Cuba, Australia, the United States, and Canada [1‐6]. Although the healthcare systems, service modes, and operation mechanisms of family doctor systems differ in different countries, the family doctor system occupies an important position in medical and health service systems. There are also some common practices and characteristics across family doctor systems. For example, the Danish General Practitioners Association [7] began to sign healthcare contracts with residents in 1973 and in Holland, residents must choose a general practitioner for signing each year [8]. There is a clear indication of the number of residents that family doctors should sign with, which is set at about 2000 people.

Development of the family doctor system in Shanghai began in 2003, with pilot work for service mode conversion implemented in Jing’an District, Changning District, Huangpu District, Pudong New Area, and Zhabei District. The public has reached a certain understanding of family doctors, and various highlights and experiences have been reported [9‐12]. Pudong implemented the family doctor system in 2010, and has focused on perfecting the management system, working mechanism innovations, optimizing service patterns and content, and promoting community health reform in general.

However, problems have been identified that require resolution, such as an inadequate contract service rate, family doctor shortages, and the absence of supporting policies [13‐15]. This study aimed to investigate the degree of implementation of the family doctor system in Pudong based on several key indicators: general practitioner/family doctor team construction, medical service coverage and contracting, service provision status, and health management services. It is important to clarify barriers to strengthening the family doctor system to provide reference information for related health policy.

In China, the basic policy for the family doctor system is to be the community’s first diagnosis system. International and domestic practice showed that promoting family doctor signing services in primary medical and healthcare institutions offered a feasible way to protect and maintain public health [16‐20]. This method is conducive to changing the model of medical and health services and allows family doctors to act as health gatekeepers. Since the State Council issued the Guiding Opinions on Establishing a General Practitioner System in 2011, pilots of different forms of family doctor signing services have been launched in various places, including team building, incentives, and evaluations [21‐26]. As early as November 2010, Pudong established the family doctor system, and since April 2012 all CHSCs in Pudong have comprehensively implemented the system. However, some issues emerged with the system implementation, such as who should provide family doctor signing services. The professionals engaged in family doctor services differ slightly across various countries, but the qualification is strictly regulated. For example, in the United Kingdom, family doctors need to complete medical professional training (including in all departments of hospital rotation training), and physicians registered with the Royal Society of Medicine are comprehensive primary healthcare personnel with clinical skills [27, 28]. In the United States, general practitioners must first demonstrate good learning achievement and medical college clinical assessment, participate in the national unified standard exam, and then complete an interview that covers issues such as personal vision to determine whether their life and value outlooks are suited to general practice [29, 30].

This study showed that family doctors in Pudong were the persons with first responsibility for providing contracted health services to the public. Family doctors were mainly registered general practitioners (including assistant general practitioners and traditional Chinese medicine general practitioners), as well as some village doctors who were deemed capable. With the development of family doctor teams, contracted service teams based around general practitioners were gradually formed, which mainly included family doctors, community nurses, public health physicians (assistant public health physicians), and village doctors. In this study, the proportion of registered general practitioners in these teams was 50.8% in 2013, but rose to 66.5% in 2016. Furthermore, with the “National Comprehensive Reform Pilot Area for the Development of Traditional Chinese Medicine,” Pudong introduced traditional Chinese medicine physicians into family doctor teams to provide special traditional Chinese medicine services. Our study found there were 236 traditional Chinese medicine physicians working as family doctors, which accounted for 19.4% of family doctor teams by the end of 2017. In addition, non-medical community assistants and community volunteers were also recruited to join the teams. In these teams, family doctors are responsible for task distribution and management of team members, and work closely with other specialists and medical technicians to provide high-quality services to contracted residents.

The present study showed that the proportion of registered general practitioners in the family doctor teams increased each year, from 50.8% in 2013 to 66.5% in 2016. Pudong had 2.1 general practitioners per 10,000 permanent residents in 2016; however, the target of the “13th Five-Year Plan for the Reform and Development of Health and Family Planning in Shanghai” is set at 4–5 general practitioners per 10,000 permanent residents. Given the current population of 5.50 million permanent residents in Pudong, at least 1045 more general practitioners are needed to achieve full population coverage. In 2014, Pudong issued “interim measures on further strengthening the construction of rural health talent team” (referred to as “eight health polices”) for rural and suburban personnel in CHSCs [31]. General practitioners in CHSCs in rural areas and suburban districts received 2000–6000 RMB/month as a work allowance, which increased work enthusiasm. However, the effect of the incentive policy may take some time to appear, and as the permanent population of Pudong is increasing each year, family doctor signing services continue to face the problem of a shortage of general practitioners.

Family doctors are the main body providing contracted services, and this study raised questions as to what form services would take and how residents sign contracts with family doctors in Pudong. Our investigation showed that residents or families can voluntarily choose one family doctor team with which to sign a service agreement. The service period for each contract is 1 year in principle. In this study, the rate of contracted permanent residents was 39.1% in 2013 and rose to 45.9% in 2016 (no statistically significant difference), whereas the rate of contracted household residents increased each year, reaching 71.7% in 2016 (significant difference from 2013 to 2016). At the same time, we found the rate of contracted household residents in suburban districts was higher than that in urban divisions and rural areas. However, the rate of contracted household residents rapidly increased. A potential reason for this observation is the relative shortage of medical resources in rural and suburban areas, which made it easier to implement the family doctor system. In addition, the stimulus policy for general practitioners (“eight health polices”) in the rural areas of Pudong took effect. Moreover, Since 2014, the “1 + 1 + 1” medical institution combination contract (a community health service center, a district-level hospital, and a municipal-level hospital) has been explored in Shanghai; therefore, when signing with a family doctor team in the community, people or families can also be recommended to a secondary or tertiary hospital for treatment in the combination medical institutions [32, 33]. This means family doctors not only provide basic health services, but also provide other services such as appointment services, two-way referral services, health counseling and education, and door-to-door services. This means family doctors have a heavy workload, which makes it difficult to guarantee service quality in Pudong. The National Health Commission and the State Administration of Traditional Chinese Medicine jointly issued “Guiding Opinions on Regulating the Management of Family Doctor Contracting Services” in 2018. This document proposed that the number of residents signed to each family doctor should not exceed 2000 in principle. However, we found significant regional differences in the number of two-way referrals by family doctors per year in Pudong. There were more referrals in rural areas than in suburban districts and urban divisions, which reflected the large demand for medical services in remote areas. Therefore, it is necessary to adopt a regionally differentiated family doctor system promotion model.

The family doctor signing service in Pudong made headway in registered general practitioner availability, the contract service rate of household residents, and providing health management services. However, we identified problems in terms of a shortage of family doctors and limited supporting policies, especially in rural and suburban areas compared with urban divisions. Therefore, to ensure the sustainable development of the family doctor system, a series of “get in, stay, and do well” tasks need to be continued. The enrollment of family doctors must be increased, and strategies such as providing apartments, children’s education, and one-time incentives to attract and retain family doctors may be needed. Speeding up the implementation of “contract service fees” may also improve the enthusiasm of family doctors to extend signing services and reflect rewarding work and rewards.