(声明：刊用《中国新闻周刊》稿件务经书面授权) (statement:reproduced[China news weekly]For the manuscript written authorization)

　　上海浦东在社区推行全科医生家庭责任制，为的是既舒缓大医院的就医难，又适应老龄化社会对于医疗的特别需要。这个方向值得肯定

Shanghai pudong in the community implementation of general practitioners family responsibility system,In order to not only eases big hospital difficult,And adapt to the aging society for medical treatment special need.The positive direction

　　本刊记者/申欣旺 郁玫( 发自上海浦东)

This reporter/ShenXinWang YuMei( From Shanghai pudong)

　　1997年5月，作为特殊人才刚从英国招聘回国的卫生管理学博士孙晓明在上海卫生系统关于全科医生的演讲，举座皆惊，原来还有这样的医生存在。

In May 1997,As a special talent just from British recruitment home health doctor of management SunXiaoMing in Shanghai health system about general practitioners speech,For seat are surprised,Originally, and this kind of doctor existence.

　　当时很难有人想到，15年后，上海浦东亦建立起这样一种制度。到2012年4月，浦东全区45家社区卫生服务中心全面开展全科医生家庭责任制。更有意思的是，当年的演讲者孙晓明成了这场改革的直接推动者。

When it is difficult to think of someone,After 15 years,Shanghai pudong also set up such a system.Until April 2012,Pudong the house of 45 community health service center to carry out comprehensive general practitioners family responsibility system.More interesting is,The speaker SunXiaoMing became the reform of direct agents.

　　改革的背景很简单：“我们卫生系统原来只有专科医生，而且是越来越专。专科医生是需要的，能够做到更加精，但不适合老龄化社会。在老龄化社会中，影响居民健康的主要因素是慢性非传染性疾病，不仅需要看病，还要对预防保健、健康教育和生活行为进行干预，这并非大医院所长。全科医生在基层，大量这类常见病依靠他们在社区就可以解决掉。”孙晓明对《中国新闻周刊》说。

The reform background is very simple:"Our health system was only a specialist,And it is more and more special.A specialist is needed,Can do more pure,But not for an aging society.In an ageing society,Affect residents health is the main factor of chronic non-communicable diseases,Not only need to see a doctor,Also on the prevention of health care/Health education and life behavior intervention,This is not big hospital director.General practitioners in the basic unit,A lot of this kind of common diseases in the community can rely on them out."SunXiaoMing to[China news weekly]said.

　　改革之前，浦东面临紧迫的老龄化问题。2010年末，浦东户籍人口275.8万，其中60岁以上的老龄人口61.29万人，占户籍人口的22.2%，接近上海23.4%的水平，远远超过全国水平13.26%的10个百分点。慢性非传染性疾病的主要患病群体越来越大，成为居民健康的主要杀手。

Before reform,Pudong face pressing aging problem.By the end of 2010,Pudong census register population of 2.758 million,The elderly over the age of 60 population of 612900,Household accounts for 22.2% of the population,Close to Shanghai 23.4% level,Far more than the national average of 13.26% 10%.Chronic non-communicable diseases main sick group is more and more big,Become residents health main killer.

　　2009年，孙晓明出任浦东新区卫生局长。他的想法很明确，必须改革，否则别无出路。随后的2010年，在孙晓明的主导下，浦东的六个社区卫生服务中心成为第一批试点，首批133名全科医生组建29支全科服务团队为签约居民服务。

In 2009,,SunXiaoMing as director of the pudong new area of health.His idea is very clear,Must reform the,Otherwise have no other way out.Then in 2010,Under the guidance of the SunXiaoMing,Pudong six community health service center became the first batch of pilot,The first batch of 133 general practitioners form and a general service team for signing residents service.

　　

全科医生更能对病人负责 General practitioners can more to the patient is responsible for

　　塘桥社区卫生服务中心医生李冬华成了首批签约的全科医生之一。接受采访的时候，李冬华提着一袋包子走进会议室，后面跟着她的病人邓阿姨。临走时，邓阿姨说包子是老爷子的早餐。

TangQiao community health service center the doctor LiDong finishing up the first signing one of general practitioners.To accept an interview,LiDongHua carrying a bag of steamed stuffed bun walked into the conference room,Followed by her patients deng aunt.When he left,Deng aunt said he steamed stuffed bun is breakfast.

　　李冬华是邓阿姨的签约全科医生，邓阿姨却说她是自己的“女儿”。“我是空巢老人。”邓阿姨用了这个现在很时髦的词，“我女儿在日本，老爷子身体不好，有什么事，首先想到的是找李医生，现在看病都在社区医院。”

LiDongHua is aunt deng the signing of general practitioners,Deng aunt said she is his own"daughter"."I'm empty nester."Deng aunt with the now very fashionable word,"My daughter is in Japan,He in poor health,What's the matter,First thought is to find doctor li,Now, a doctor in community hospitals."

　　这正是孙晓明想要的结果。他告诉《中国新闻周刊》一组世界卫生组织的数据：80%的疾病可以在社区解决，只有20%的疑难杂症和重病需要在大医院解决。但中国的情况却正好相反，人们都奔大医院去，社区医院门庭冷落。

This is what SunXiaoMing want results.He told[China news weekly]A group of the world health organization of data:80% of the disease can solve in the community,Only 20% of incurable diseases and serious illness need in major hospitals to solve.But China's case is opposite,People rush to go to large hospital,Community hospital swing left out in the cold.

　　浦东希望通过全科医生的改革走出这个困境。

Pudong hope that through the reform of general practitioners went out of the dilemma.

　　不过，社区医院的劣势是现实存在的。孙晓明说，相对于英国全科医生和专科医生对应的医疗体系，我国上世纪50年代学苏联，都是按照一二三级医院建立，里面都是专科医生，即便是社区医院层面也是如此，不同的只是医疗水平高低。

but,Community hospital disadvantage is real.SunXiaoMing said,Relative to the British general practitioners and specialists corresponding medical system,The last century in our country 50 chronology the Soviet union,According to two tertiary hospital set up,There is a specialist,Even so it is community hospital level,The difference is in the medical level.

　　这样一来，社区居民没有理由选择医疗水平低的社区医院。以社区医院为主体的全科医生改革拿什么吸引病人？塘桥社区卫生服务中心主任黄煊用4S店来比喻自己的优势。“汽车跑五万公里要保养，人也一样，社区医院就是居民健康的4S店，能够为健康提供超级预警，解决大量的常规问题。”

so,Community residents have no reason to choose medical level low community hospitals.In community hospitals as the main body of the general practitioners reform take what attract patients?TangQiao community health service center director HuangXuan with 4 s shops to describe their own advantage."Cars run fifty thousand kilometers to maintenance,People too,Community hospital is the health of the residents of 4 s shop,Be able to provide health super early warning,To solve a lot of conventional problem."

　　这些常规问题包括，心脏病、糖尿病等疾病的日常治理，大病转诊后的护理，疾病预防，健康教育。在这些问题的处理上，社区医院有着大医院无法比拟的优势。黄煊说，“我们的签约医生要对他的病人负责，病情变化、用药情况，他全部掌握，对病人非常熟悉。”

These conventional problems including,Heart disease/Diabetes disease daily management,A serious illness after referral of nursing,Disease prevention,Health education.In these problems in processing,Community hospital has big hospital incomparable advantages.HuangXuan said,"Our signing the doctor to his patient is responsible for,Condition changes/resoures,All his master,The patient is very familiar with."

　　还有一个优势便是信任关系。有一次，邓阿姨家老爷子吐血，到三甲医院就诊，门诊专家开了药，邓阿姨习惯性地把药名告诉李冬华。“吐血怎么开的是活血的药？”李冬华建议邓阿姨再去问大夫。

There's another advantage is trust relationship.once,Deng aunt house vomiting blood,To 3 armour hospital,Outpatient service experts opened medicine,Deng aunt habitually to tell LiDongHua drug."Vomiting blood how open is promoting blood circulation of medicine?"LiDongHua suggest deng aunt again to ask the doctor.

　　“我去找门诊的专家。他一听我说，马上跳起来，连说对不起，说马上停药。要不是李医生，后果不堪设想。”说这番话的时候，邓阿姨眼中满是信任和温暖。

"I went to look for outpatient service of experts.He listen to me,Jumped up and,Even say I'm sorry,Said immediately stop drug.If it weren't for doctor li,Consequence is unimaginable."Say these words time,Deng aunt eyes is full of trust and warm.

　　邓阿姨说，并非怀疑大专家的医术，“只是他们一天看那么多，根本没有时间了解病人全面情况。”

Deng aunt said,Not doubt big expert medical skill,"They just one day to see so many,No time to learn about the patient overall situation."

　　这正是目前医疗领域备受诟病之处。孙晓明认为，这并非某个医生职业道德不行，“专科医生重点是看病，有病才找他，与病人之间不是固定关系，无法实行全程、连续性、综合性健康管理和干预。”。”

This is at present in the medical field for the place.SunXiaoMing think,This is not a doctor professional ethics can't,"A specialist key is a doctor,Sick to find him,And the patient is not fixed relationship between,Cannot implement whole/continuity/Comprehensive health management and intervention."."

　　医疗界曾流传一个笑话。一位痔疮病人碰见给自己看病的专家，赶忙打招呼，专家点点头。在诊室中，看到这位病人的屁股，专家恍然大悟：“原来是你呀。”

Once supported spread a joke.A haemorrhoid patient met give yourself a doctor of experts,Quickly say "hello",Experts nodded.In the clinic of,See the patient's ass,Experts take a tumble:"That was you!."

　　这个笑话虽然极端，但将医患之间的尴尬关系描绘得淋漓尽致：由于门诊大夫轮流出诊，医生根本无法记住病人，更别说对症下药了；病看好看坏，也找不到责任主体。

The joke though extreme,But will the doctor-patient relationship between awkward described incisively and vividly:Due to the clinic doctor take home visit,The doctor couldn't remember the patient,Let alone the suit the remedy to the case;Disease valued look bad,Also can not find responsibility main body.

　　全科医生则正好解决这个问题。在大团社区卫生服务中心，几位农村的签约病人告诉《中国新闻周刊》，“现在看病完全在社区卫生服务中心，不会再去大医院了，这里更方便，直接找自己的医生就行了，医生对自己的健康情况非常了解。”他们的签约医生俞真旺甚至被其中一位病人称呼为“亲戚”。

General practitioners is just to solve this problem.In the mass of community health service center,The signing of several rural patients tell[China news weekly],"Now the doctor completely in community health service center,Won't go to large hospital,Here is more convenient,Direct, looking for his own doctor went,The doctor for their own health situation is very understanding."Their signing the doctor YuZhen flourishing even one of the patients to call"relatives".

　　信任的基础则是居民的参与。潍坊卫生服务中心主任杜兆辉告诉《中国新闻周刊》，解决这个问题第一步需要建立好契约关系。潍坊的办法是，全科医生直接到社区去，做三项工作，一是向居民具体解释有哪些服务，取得患者认同；二是留下自己的联系方式和出诊信息；三是帮助他们在电子签约系统中签约。通过这些信息的采集，协助居民建立健康档案。

Trust is the foundation of the participation of residents.Weifang health service center director DuZhaoHui tell[China news weekly],To solve this problem is the first step to build a contractual relationship.Weifang way is,General practitioners directly to the community to,Do three work,One is to residents explained what service,Get patients identity;The second is leave your contact information and house call information;Three is to help them in the electronic contract signing in the system.Through these information collection,Assist residents to establish health files.

　　农村的情况又不一样。大团卫生服务中心主任王正平说他们的办法是宣传发动，“我们到每个村去，十几个人下去，现场免费检查身体、量血压、做B超，实惠的东西农民朋友喜欢，然后集中签约，事半功倍。”

Rural condition is not the same.Mass of health service WangZhengPing, director of the center said their way is propaganda launch,"We to each village to,Down more than a dozen people,The free inspection body/Blood pressure/Doing B to exceed,What benefits farmers friends like,Then concentrated signing,Twice the result with half the effort."

　　通过各种不同的探索，截至2012年7月31日，整个浦东签约276484户，签约人数达到457621人，建立了超过110万份健康档案。

Through the different kinds of exploration,By the end of 2012 on July 31,,The entire pudong signing 276484 households,The number of signing up to 457621 people,Set up more than 1.1 million copies of health files.

　　

做健康和费用的双重“守门人” Do health and cost double"porter"

　　通过签约，全科医生服务的基础得以建立起来。在这个基础上，杜兆辉说，他要做的是怎样让全科医生愿意做好这个工作。“有了好的构架，还需要建立内在的机制，调动医生的积极性，不是领导讲几句话就可以让人热火朝天地干事。”

Through the signing,General practitioners service foundation to set up.On this basis,DuZhaoHui said,He wants to do is how to make general practitioners are willing to do this job."Have a good frame,Also need to establish internal mechanism,To mobilize the enthusiasm of the doctor,Leadership is not to say a few words can make people in full swing to stewards."

　　杜兆辉讲的机制中，签约病人可以预约来看门诊，只要在约定的时间段内，预约的病人不用排队就可以看病。

DuZhaoHui said mechanism,Signing the patient can make an appointment to see outpatient service,As long as at the appointed time,Make an appointment of patients don't queue can see a doctor.

　　还包括对医生的激励，看一个普通门诊给医生的挂号费0.5元，看一个签约病人门诊是1.5元，而一个签约病人通过预约来的则需3块钱。

Also include the doctor's incentive,See a general outpatient service to the doctor's registration fee 0.5 yuan,See a sign patient outpatient service is 1.5 yuan,A signed by an appointment to the patient is required three dollars.

　　“绩效考核是个杠杆，医生会主动做好病人的工作，提供细心的服务，当然也包括认真对待病人的病情，让他们信赖全科医生。”杜兆辉说。

"Performance evaluation is a lever,The doctor will be active to the patient's work,Provide attentive services,Of course also includes serious about the patient's condition,Let them trust general practitioners."DuZhaoHui said.

　　虽然农村和城里的情况完全不同，王正平的目标却一样。当他发现签约的农民半个月都没有找全科医生，也没有人打电话来的时候，便要求医生们都到农村去，每家每户要走一遍，真正去了解病人的情况。

Although rural and city, the situation is different,WangZhengPing goal is the same.When he found signing farmers half a month are not looking for general practitioners,And no one to call time,He asked the doctor are going to the countryside,Every household to go again,Really to understand the patient's condition.

　　财政支持的40万元就成了下乡补贴，谁的工作做得好，谁就能拿到更多的费用。

Financial support the 400000 yuan became to subsidies,Who work well done,Who can get more expenses.

　　只要下去了，就能解决问题，效果立竿见影。俞真旺有很深的感触，“有一次下乡，在一个患有痛风的病人家中，看到桌子上放着利尿剂的药瓶。这个病人痛风病看了20多年，一直没有效果。原来是因为痛风不能吃利尿剂。”

As long as down,Can solve a problem,Immediate effect.YuZhen prosperous have deep feelings,"Have a go to the countryside,In a patient with gout home,See table the use of language.This patient gout disease see more than 20 years,Has no effect.Because gout can't eat diuretics."

　　“大医院看病，有时候没问得这么细，农村的病人也不清楚应该告诉医生哪些事，就这么耽误了。”俞真旺说，后来这个病人还是因为肾病去世了，可是他的家人仍然很感激。

"Big hospital,Sometimes didn't ask so fine,Rural patients also don't know should tell the doctor what things,So the delay."YuZhen prosperous said,Later, the patient died or because kidney disease,But his family still appreciate it.

　　信任一旦建立起来，对全科医生的认同度直线上升。像俞真旺、李冬华这样和患者亲密互动的例子，几位社区卫生服务中心主任可以信手拈来。

Trust once established,The identities of general practitioners in a straight line.Like YuZhen flourishing/LiDongHua such and patient close interaction example,Several community health service center director can exist.

　　孙晓明告诉《中国新闻周刊》，“2011年6月开展的全科医师家庭责任制工作基线调查结果显示，签约对象对全科团队服务的满意度达到90%以上。”

SunXiaoMing tell[China news weekly],"June 2011 to general practitioner family responsibility system work baseline survey,Signing the object to general team service satisfaction above 90%."

　　随着基础工作的到位，孙晓明考虑的是，将老百姓医疗费用的支付与全科医生的考核对接起来，让全科医生不仅成为老百姓健康的“守门人”，还要成为老百姓医疗费用的“守门人”。“我们现在的社保制度是按项目后付费，根据检查花了多少钱、手术花了多少钱、药费多少钱最后结账，这样带来的最大问题是浪费：大检查、大手术都出现了，钱永远不够用。”

As the basic work of in place,SunXiaoMing consider is,Will people medical expense payment and general practitioners assessment and butt up,Let the general practitioners not only as the health of the people"porter",Will become common people of medical expenses"porter"."Our present social security system is to pay after the project,According to check how much money/How much surgery/Expenses for medicine how many money finally settle accounts,This is the biggest problem with waste:examination/Major surgery are appeared,QianYongYuan not enough use."

　　孙晓明说，“全科医生的支付手段则完全相反，今年8月，浦东新区卫生局首先在拥有34万参合人群的新型农村合作医疗中实行按人头预付制度按照人头将费用的90%预付到社区卫生服务中心，10%留在合作医疗管理办公室作为风险基金，到中心的资金由全科医生省着用，多花的算医生的，节省的钱有奖励，这样他就会努力节约，多做预防和保健。”

SunXiaoMing said,"General practitioners means of payment of the exact opposite,August,Pudong new district health bureau first at the 340000 ginseng adds up to the crowd in the new rural cooperative medical practice on a per head prepaid system according to the nominee will cost 90% advance to community health service center,10% in cooperative medical management office, a risk funds,To the center of capital by general practitioners province with,Flowery calculate the doctor's,Save money are rewarded,So he will save effort,Do more prevention and health care."

　　这样做的逻辑是，孙晓明说，“每个全科医生都会想，我管的人一定要少生病，最好不生病。这就把原来医生希望多生病，最好都是大病，多发生医疗费用，医院收入高，医生收入也随之增加的利益导向机制扭转过来了将有限的合作医疗基金用到极致，发挥最大效益。”

Do this logic is,SunXiaoMing said,"Each general practitioners will want to,I tube people must have less sick,Had better not sick.This is the original doctors hope to many ill,The best is a serious illness,Many medical treatment charge happens,Hospital income high,The doctor income also increased interests guide mechanism turn over the limited fund of cooperative medical treatment use extreme,Maximum benefit."

　　

中国的现实困境 China's dilemma

　　尽管让全科医生来控制费用在全世界范围都是通例，因为只有医生才知道病人需要用什么药、要做什么检查。但这个做法在中国推行起来并非易事。

Although let general practitioners to control the cost in the worldwide are established,Because only the doctor didn't know patients need to with what medicine/What to do inspection.But this practice in China implement up is not easy.

　　难处在于，按照目前的保险制度，老百姓拿着一张医保卡可以在一定的辖区所有医院自由看病，控制医疗费用几乎没有可能。

Difficulty lies in,According to the current insurance system,People with a piece of medical insurance card can in some jurisdictions all hospital free to see a doctor,Control medical cost is almost impossible.

　　潍坊社区卫生服务中心的全科医生胡冰说，“很多老百姓信任我们医生，看病总找我们，可是不愿意签约，原因很简单，他们担心一旦签约，只能在这一个医院看病，更不自由了。”

Weifang community health service center of general practitioners ms.bing hu has said,"A lot of people to trust us the doctor,The doctor always find us,But don't want to sign,The reason is very simple,They worry that once signing,Only in this hospital,Less free."

　　王正平也说，“医生做十天的宣传，还不如老百姓说一句质疑的话，只要某一个人说，签约以后不自由了，就会有一大片拒绝签约。”

WangZhengPing also said,"The doctor do ten days of publicity,Not a word people question,As long as one person said,After signing not free,There will be a large refusing to sign."

　　浦东卫生局双管齐下应对此种困难。一方面，在一个社区安排多个全科医生，通过竞争让老百姓自主选择医术高明、称职的全科医生，达到提高服务的目标；另一方面，在试点单位推行和大医院双向转诊的绿色通道，在目前一号难求的情况下，为真正需要到大医院就诊的病人创造条件。

Pudong health bureau to deal with the difficult work.On the one hand,In a community arrangement more general practitioners,Through the competition let common people choose learned/Qualified general practitioners,To improve the service goal;On the other hand,In the implementation of the pilot units and large hospital two-way referral of the green channel,At present it is difficult to find a number of cases,For really need to hospital patients to create conditions.

　　但这种做法难处显而易见，三级医院并没有动力配合社区医院转诊，而社区医院床位紧张，想往下转诊也不是那么容易。

But this kind of practice is obvious difficulties,Tertiary hospital and no power with community hospital referral,And community hospital beds nervous,Want to go to next referral is not so easy.

　　浦东的做法是，从今年开始，先行在农村试点，探索固定就诊和全科医生控制医疗费用的可行性。

Pudong practice is,From the beginning of this year,First in rural pilot,Explore the fixed medical and general practitioners the feasibility of controlling medical expense.

　　困难还包括，目前全科医生数量和质量都远远不够。仅从数量上来看，孙晓明说，国际上通行的标准时，每名全科医生负责2500个居民，按新区2011年常住人口517.5万计算，如要达到这一要求，实现全人群覆盖，新区至少需要全科医生2000名。目前新区有注册的全科医生869名，加上其他社区医生总共1300名，至少缺700名。

Difficult also includes,At present general practitioners quantity and quality are far from enough.Only from the Angle of quantity,SunXiaoMing said,Internationally standard time,Every name general practitioners responsible for 2500 residents,According to the new permanent population of 5.175 million 2011 calculation,If you want to achieve this one requirement,To realize the whole crowd cover,The new general practitioners need at least 2000.At present the new general practitioners have registered 869,Combined with other community doctor a total of 1300,Lack of at least 700.

　　最为关键的仍然是，全科医生和社区医院的医疗水平怎么样？“舍近求远去大医院的就诊习惯说到底还是因为社区医术水平仍然不高。”孙晓明说。

The most crucial is still,General practitioners and community hospital medical level?"Cooperate go to large hospital medical examination habits after all or because the community medical skill level is still not high."SunXiaoMing said.

　　上世纪末，黄煊得益于一个项目的资助，被派到美国爱荷华大学进修三个月。“我跟的马可教授是家庭医学系的教授，同时也是全科医生，这和我们中国的概念完全不同，西方国家的全科医生本身就有很多专家。”黄煊说。

The end of last century,HuangXuan benefited from a project funding,Was sent to the university of Iowa study three months."I told the professor mark is professor of family medicine,At the same time is also general practitioners,This and the concept of our China is totally different,Western general practitioners itself has many experts."HuangXuan said.

　　孙晓明想做的是，创造条件，吸引三级医院的专家到社区医院兼任全科医生，“上海去年出台一个政策，允许多点执业，这很有意义，原来是非法的。如果大量好的医生下到基层去，对于解决全科医生的质量问题，就能夯实基础。同时，上海要加快全科医生规范化培养的速度，大幅度提高全科医生的社会地位和待遇，让全科医生成为全社会所羡慕的崇高职业，全科医生队伍素质提高了，人民群众的健康就有根本保障。” ★

SunXiaoMing want to do is,Create conditions,Attract tertiary hospital experts to community hospital concurrently general practitioners,"Shanghai last year issued a policy,Allow more practice,This is very meaningful,It is illegal.If a large number of good doctor down to grassroots to,To solve the quality problem of the general practitioners,Can the solid foundation.At the same time,Shanghai to speed up the general practitioners standardization training speed,Greatly improve the general practitioners of social status and the treatment,Let the general practitioners habits become the envy of noble career,To improve the quality of the general practitioners team,People's health is the fundamental guarantee." painted