38
THE ROLE OF PATIENT VALUE AND PATIENT-CENTRED
CARE IN HEALTH SYSTEMS
70 Gordon Liu et al, “China’s Health Reform
Update,” Annual Review of Public Health,
2017.
71 Huixuan Zhou et al, “The development
of indicator measure for monitoring the
quality of patient-centered care in China’s
tertiary hospitals,” PLoS One, 2018.
72 Gordon Liu et al, “China’s Health Reform
Update,” Annual Review of Public
Health, 2017; Huixuan Zhou et al, “The
development of indicator measure for
monitoring the quality of patient-centered
care in China’s tertiary hospitals,” PLoS One,
2018.
73 William Wong et al, “Primary care
workforce and continuous medical
education in China,” BMJ Open, 2017;
William Wong et al, “Availability and
use of primary care facilities in China: a
nationwide representative survey,” Lancet
(poster abstract), 2016.
74 Xi Li et al, “The primary health-care system
in China,” Lancet, 2017.
75 Cheris Chan, “Mistrust of physicians in
China: society, institution, and interaction
as root causes,” Developing World Bioethics,
2017.
76 “Chinese doctor stabbed to death after
row with patient’s husband,” South China
Morning Post, March 15th 2018; “Beaten,
stabbed and threatened: who’d want to
be a doctor in China?” Inkstone, March
16th 2018; “China’s Health Care Crisis: Lines
Before Dawn, Violence and ‘No Trust,’” New
York Times, September 30th 2018.
77 Therese Hesketh et al, “Violence against
doctors in China,” BMJ, 2012.policy process, or discussions on insurance or healthcare service delivery. China has a long way to go,”
in that respect.This lack of formal communication helps explain some shortfalls of the 2009 reforms. One is the lack
of reorientation in practice toward primary care. Mr Liu notes that national statistics from 2010 to
2017 show that the number of people using community health facilities stayed largely flat or rose only
slightly over those years but show “a significant increase in the number of visits to tertiary hospitals
in that time. In other words, the situation where people go to hospital for outpatient care has not
improved. It has worsened.”The explanation is twofold. First, increased insurance coverage has allowed more use of secondary
and tertiary care rather than needing to rely on local facilities. More important, patients are convinced
that the quality of care available in primary institutions is far inferior to that in hospitals, especially
major ones in large cities.^70 Accordingly, China’s tertiary hospitals, which make up 8% of healthcare
institutions, account for 48% of outpatient activity.^71 They are swamped, unable to keep up with
demand, with patients waiting from 2.5 to 8 hours in order to have a 15-minute consultation.^72By some measures, patients have a point about primary care: roughly half of those practising as
GPs in grassroots clinics lack even a bachelor’s degree; only 64% of clinics are equipped to do basic
gynaecological examinations; and misdiagnosis is common.^73 However, extremely brief occasional
outpatient appointments with overworked but better trained clinicians do not necessarily lead to
better outcomes. A study of patients with hypertension and diabetes found that diagnosis and control
rates were poor across the board and only very slightly better among those who got care exclusively at
hospitals compared with those using primary clinics.^74Getting people to use primary facilities may require better clinicians, but communication with patients
will also be necessary so that health planners can understand what would make them more attractive.Such interaction will also be needed to solve another major issue bedevilling Chinese healthcare.
Patient lack of faith in primary clinicians is part of a wider mistrust of all medical personnel. One recent
two-year ethnographic study found that almost all the patients and family members it interviewed
distrusted physicians to some degree.^75 Indeed, violence against doctors and nurses by unsatisfied
patients—known as yi nao, or medical disturbance—has for some years been a major social problem.
In a 2016-17 Chinese Medical Doctor Association survey, 66% of physicians reported experience of
physical or verbal abuse. Meanwhile, the Supreme People’s Procuratorate reported in early March 2018
that since 2016 it had prosecuted 7,816 people for intentionally injuring medical staff or inciting crowds
at hospitals.^76 Disgruntled patients can even hire specialised criminal gangs to intimidate clinicians to
get better care.^77The strained relations between patients and clinicians is not a result of poor levels of technical
competence or clinical experience, says Mr Liu. He believes Chinese hospital doctors are not far behind
those in the West in these areas. Because of the volume of people who want their services, however,
these clinicians have “very, very limited time for interaction. Chinese patients would value a better