| 1.Research BackgroundThe family doctor service has been an important part of community health service reform in recent years.Since the State Council issued guidelines on the establishment of a general practitioner system in 2011,the nation,various provinces and cities had introduced relevant policies respectively to carry out the pilot work.In 2016,the seven ministries and commissions of the state jointly formulated the Guidance Opinions on promoting the contract service of family doctors,which once again highlighted the significance of promoting the family doctor service.In March 2014,the guangzhou municipal health and family planning commission jointly with the guangzhou municipal human resources and social security bureau established the guangzhou grassroots medical institutions to carry out the family doctor service work plan.Since 2014,the pilot work of the Guangzhou family doctor service has been carried out for a certain period of time,how has the try-program progressed?What kind of cognition has the supply and demand sides(community health workers and residents)formed?Has the operation effect reached the initial goal set in the policy?In the process of pilot work,the health and family planning commission of Guangdong Province issued guidelines on the team performance evaluation index system of the family doctor service,which was offered to evaluate the cities' pilot work.Based on the guidelines and the reality of Guangzhou,the purpose of this study is to establish a set of evaluation tools with strong operability.More importantly,this study,exploring an approach of combining the evaluation tools with the situation investigations.aims to analyze and evaluate of the pilot work of two districts in Guangzhou,explore its achievements and existing problems,and discuss the condition of Guangzhou on this basis.2.Research ObjectsWe aim to establish a set of evaluation index system on family doctor service through Delphi method,,suitable for actual Guangzhou and available for the health administrative department of the district;understanding the community health workers' and residents' cognition to family doctor service by carrying out the situation investigations;through the comprehensive analysis of the situation investigations and the evaluation system,understanding the developing state and effect of the family doctor service in Guangzhou,and providing evaluation tools and evaluation model for the family doctor service carried out in Guangzhou;exploring the existing problems in the process of the family doctor service carried out in Guangzhou,in order to provide the basis and reference for perfecting family doctor service policy in Guangzhou.3.Research MethodsLiterature research method:through consulting relevant literature and policy documents,based on the evaluation index system issued by the health and family planning commission of Guangdong Province,preliminary to draft the evaluation system.Delphi method:selecting experts from related fields to carry out two rounds of expert consultation,establish evaluation system,and determine the weights and combination weights of indicators at all levels with the method of "hundred power division".The positive coefficients of two rounds of consultation were 100%and 93.75%,respectively.After two rounds of consultation,the coordination coefficient of experts was 0.49,and the significance test showed P<0.05.Questionnaire survey:through giving out questionnaires to community health workers and residents to investigate the status of family doctor service in Guangzhou;Epidata 3.1 and excel 2010 were used to input data,and spss 20.0 was used to conduct statistical analysis,such as descriptive statistics,t test,variance analysis,rank sum test and the like.4.Research Results4.1 The establishment of the family doctor service effect evaluation index systemThe study established the index system of three primary indexes,eight secondary indexes,and 29 tertiary indicators.4.2 Findings of situation investigations500 questionnaires were issued to medical staff,of which 444 were effectively recovered,with an effective rate of 88.8%.Among the 444 medical staff,87.6%knew the family doctor service,49.1%thought that the implementation is not smooth at this stage,59.9%felt more tired at work,67.1%thought that after the implementation of family doctor service the workload increased,and 91%said the implementation of family doctor service has not brought any change in income,and they had the lowest satisfaction(2.93 points)to the salary,which was between dissatisfaction(2 points)and general satisfaction(3 points).600 questionnaires were issued to the residents,of which 525 were effectively recovered,with an effective rate of 87.5%.The residents' awareness rate of the family doctor service was 63.4%,and they obtained the related publicity information mainly by means of the publicity of community health service institutions and the publicity of TV.radio,and newspapers;of the 195 contracted residents.28.7%sought for the service from signing team after signing a contract service,35.9%showed their clinic visits in the community hospital increased after signing,67.8%and 80.5%had not yet received the appointment and referral services,receptively.The overall satisfaction of signed residents to the family doctor service was(3.646 points)to reach the general satisfaction(3 points)to a satisfactory level(4 points).In this study,we investigated 20 community health service centers held by the governments at two districts(10 centers each)in Guangzhou.As for the family doctor team structure,each community health service center assembled a team,based on their actual conditions.The team number was in the range of 4 to 13,and every team was equipped with a general practitioner,a public health physician and a nurse.Besides,every team established the corresponding responsibilities,work flow and internal assessment system.As for the implementation of signing service,20 community health service centers in two districts had a total of 15178 residents signed,and the average population signing rate was 1.27%.Signed numbers of 10 centers in District B average(1297.9)is higher than that in A(219.9),and the difference was statistically significant(P<0.05).In the 20 community health service centers,the average appointment rate of contracted residents was 4.83%,and the referral rate for the contracted residents through a family doctor was low(average referral rate was 0.465%),while the consultation rate in a family doctor's reached more than 40%.As for the service effectiveness of three key groups,there were 5 indicators(hypertension coverage rate,standard management rate of hypertension,management coverage rate of diabetes,standard management rate of diabetes,health management rate of the elderly)judged by national standard.Among the community health service centers,10 reached the national standard(35%)on the hypertension management coverage rate;7 reached the national standard(50%)on the standard management rate of hypertension:10 reached the national standard(30%)on the management coverage rate of diabetes;6 reached the national standard(50%)on the standard management rate of diabetes;20 failed to meet the national requirements(65%)on the health management rate of the elderly.4.3.Comprehensive evaluation of the family doctor service effect in GuangzhouThe comprehensive average score of two district was 73.66.of which the average score of B area was 74.04,higher than the 73.28 of A area.According to a single community health service center' s scores,20 community health service centers' scores vary from 69.28 to 79.46.85%(17/20)of the community health service centers scored 70 points or more,55%of the community health centers(11/20)scored more than the total average score(73.66 points),and the gap of the highest score(79.4608)and the lowest score(69.2775)was more than 10.In view of the three dimensions of the evaluation,team management had the highest score(32.98 points),the second was the social effect score(22.8746 points),and the service function obtained the lowest score(17.805 points),which indicated that much importance were attached to the team management by the two districts at present stage in the implementation process of the family doctor service,the substantive results obtained should be improved,however.5.ConclusionFamily doctor service pilot work in Guangzhou at current stage has achieved certain results,in the form of the high public awareness rate,the development of health consciousness,satisfaction residents showed with the family doctor service,and the emphasis put on the team management in the implementation process.But the current rates of appointment and primary diagnosis are not high,and the family doctor service has limited impact on the ability of residents to form a hierarchical diagnosis and treatment.In addition,the study reveals the problem:family physician services are poorly publicized;The medical staff have a low understanding of the family doctor service,and residents have a Low awareness of the content and connotation of a family doctor service;The supporting policies are incomplete and the effective service model is not formed;There is a lack of effective incentives for medical staff and residents to sign up;The goal of a family doctor service is not ideal and has Larger difficulty;The family doctor service supply quality is not high and a simple one,failed to guide,dock,and release residents' demand,High quality and effective supply and low levels of simple oversupply coexist.As the demand side,residents do not have a high level of identification of the family doctor service,get general service experience,the demand is not clear nor strong,the supply of available is blurred;The community has a severe shortage of human resources and does not match the workload;The construction of informationization lags behind and restricts the efficiency and efficiency of family doctor service.Aimed at these problems,several corresponding countermeasures are proposed:improving the medical staff's and residents' awareness of family doctor service through the establishment of training base and the joint promotion mechanism of sub-district office;strengthening the supply-side reforms of the family doctor service to meet the medical needs of residents;setting up realistic policy targets and conducting regular investigation and timely adjustments;improving the supporting policies,accelerating the establishment of the signing service fee system,exploring medical insurance payment mode of signing-service fees according to the number of people,gradually improving the two-way referral system,and enhancing the contract-signing power of medical staff and residents;designing the reasonable salary,job title and training system,strengthening the construction of general practitioners,and increasing the reserves of the grass-roots personnel;improving the information construction and the work efficiency of medical staff;establish a multi-sectoral linkage system to create a social engagement atmosphere... |
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