"If you want to leave the county hospital, you will have to break the contract and pay hundreds of thousands, but if you don't leave, I will be almost thirty years old after fulfilling the contract, and my roots have already taken root, and I can't leave if I want to."
Liu Yue (pseudonym), who graduated the year before last and was directed to work in the county hospital, said: "When filling out the college entrance examination volunteer, the score directed to the county hospital was about 20 points lower than the general clinical practice of the school, and at that time, my family's "seeking stability" made me study clinical medicine in the county hospital of my hometown, but as I learned more and more about the profession and industry, I found that my ambitions did not stop there.
After graduating from undergraduate school, I want to go to graduate school and go to a big city, but I can't leave. In the past few sessions, many people broke the contract and left, and the policy was tightened when they came to us, and I couldn't take out so much money. I went to elementary school, junior high school, and high school in my hometown, and I came back to work after graduating from university, and I didn't go out to see it when I was young, which is a bit of a pity."
And Liu Yue's experience may be just a silhouette of the medical workers in the county hospital.
Under the wave of big three expansion
In recent years, the radiation range of large tertiary hospitals has become more and more extensive, and earlier, this radiation was manifested in the increase in the number of beds in individual hospitals.
In 2014, the National Health Commission issued an emergency notice on controlling the excessive expansion of the scale of public hospitals: in recent years, the scale of mainland public hospitals has expanded too rapidly, and some hospital units are too large, and there are problems such as pursuing bed scale, competing to purchase large-scale equipment, and ignoring the internal management and mechanism construction of hospitals, which has increased the unreasonable growth of medical expenses, squeezed the development space of primary medical and health institutions and non-public hospitals, and is not conducive to hospitals improving service quality and management level.
However, the expansion of tertiary hospitals has not stopped.
We have written about the fact that medical resources always flow to the highlands to the wastelands. Hospitals will move from "medically developed areas" to relatively "medically backward areas" in order to seek better development, and this logic is similar to the "red ocean" and "blue ocean" in business.
In the medical field, the resources carried by the hospital are not only limited to talents, equipment, buildings, funds, but also the tangible or intangible influence of the hospital, for a city, a large tertiary hospital provides essential functions, especially in the planning of the new urban area of the city, the top three must shoulder the responsibility of urban services.
Under the heavy trust, the scale of the tertiary hospitals has also become larger and larger. In the general direction of controlling the scale of individual hospitals, the expansion of new campuses has become a new trick for hospitals.
However, the other situation is not limited to the "urban expansion" of the relative plane, but a kind of "downward" precipitation - the expansion of the big three is more and more inclined to the grassroots.
In 2021, as a key project in Sichuan Province, West China Hospital rushed to Leshan City to build the Emei Branch, which will be fully operated and managed by West China Hospital after completion.
After the development of Fujian Pingtan Comprehensive Experimental Zone, the Union Hospital Affiliated to Fujian Medical University was burdened with the "Overall Development Plan of Pingtan Comprehensive Experimental Zone", taking advantage of its geographical advantages to sink Pingtan Island nearby, build a branch, and take turns to send staff stationed in the headquarters to the branch for study and work.
As the number one hospital in Fujian Province, after its sinking island to build a branch, the original hospital on the island will inevitably appear to be discolored. Under the wave of big three top class expansion, there are more county-level hospitals that are facing such a situation.
欲攘外者,必先安内
In 2015, the Guiding Opinions of the General Office of the State Council on Promoting the Construction of a Hierarchical Diagnosis and Treatment System was released. Among them, it is proposed to comprehensively improve the comprehensive capacity of county-level public hospitals, increase the medical treatment rate in the county to about 90%, and basically realize that serious diseases do not leave the county.
However, for the county hospital, its own development at this stage still faces a double dilemma inside and outside.
In the survey on the development prospects of county-level hospitals launched by Lilac Garden Weibo, more than 43% of county-level hospital doctors believed that the siphon effect of large hospitals was significant, and it was difficult for county-level hospitals to retain talents and resources, and about 22% of doctors believed that the situation of county-level hospitals was somewhat embarrassing, "It is difficult to compete with community hospitals and third-class hospitals."
Source: Lilac Garden Weibo screenshot
Externally, county hospitals face competition with the community and the top three.
In the early promotion and implementation of graded diagnosis and treatment, many places have played the slogan of "major diseases enter the hospital, minor diseases enter the community". But in this slogan, the classification of "hospital" and "serious illness" is another complex discipline.
Another county hospital doctor, Qin Qiulin (pseudonym), said that his hospital is facing such a development dilemma: "The main thing is that people are floating around, and the equipment can keep up, but the technical level is slow to update." Because those who come to our hospital to see a doctor are either minor illnesses, or the patient's family is really difficult, and those who have a little way will go to the province."
While community hospitals have geographical convenience, tertiary hospitals have strength advantages, and the relatively awkward positioning makes the county hospital slightly weak in external radiation. In 2018, Guangming Daily published an article asking "How should city and county hospitals in the "sandwich layer" be positioned"? It is pointed out that the siphon effect of provincial tertiary hospitals is significant, while the bed space of county-level hospitals is vacant.
Internally, county hospitals are facing many problems in their own construction, including equipment, talents, funds, systems and so on.
In Qin Qiulin's view, the construction of the talent team hinders the development of the county hospital: "In the county, the treatment of the star doctor is very good, and the patients in the entire county recognize him alone. But such a famous doctor is adding every day, and almost no one can take the baton. Young doctors can't be recruited, can't stay, and talent gradient can't be built."
The young doctors who remain in the county hospital are either doctors who "accumulate qualifications" in the county hospital and seek the opportunity to change jobs; Either it is Liu Yue, a medical student who signed a directional agreement as early as the college entrance examination, and for Liu Yue, it has always been a pity that he cannot continue his studies and improve his clinical level like other classmates, and cannot leave the narrow circle.
Under the dual role of internal and external environment, county hospitals are prone to fall into the cycle of brain drain and patient drain. Conversely, if you want to leave the loop, you need to start with the first node of the loop.
As Zhao Pu said, "Those who want to conquer the outside must first settle inside."
to be or not to be,that's a question
County hospitals saw the need for reform and found three paths for themselves.
One is to become a "medical community". Before the big hospital is killed, the current group is held within the county, giving full play to the advantages of grassroots rooting, and fighting a "difference war" with the third-class hospital.
Sanming City, Fujian Province, known for its "Sanming Medical Reform", has also made some moves in the reform of county hospitals. After 2017, it carried out a large-scale integration of primary medical and health resources, and established a "county general hospital" within each county and county, integrating the original county hospital, traditional Chinese medicine hospital, maternal and child health care hospital, health center and other medical institutions to establish a "county general hospital" to expand its own radiation scope.
Image source: Screenshot of Mingxi County General Hospital
The second is to become bigger and stronger and become a "single strong". From a tertiary county hospital to a tertiary county hospital, the way not to be defeated by a tertiary hospital is to become a third-class hospital. However, because tertiary hospitals have hard requirements such as beds, departments, and physician titles, for hospitals, the area must have a certain foundation.
In recent years, most of the county hospitals rated as tertiary or tertiary are county-level cities in economically developed provinces, which have a large population base and can support medical services and the hospital's talent introduction strategy.
The third is to cooperate with regional tertiary hospitals and become part of their medical alliance. In contrast, the third-class hospital will provide technical guidance for the county hospital, and members of the medical consortium will also have greater convenience in telemedicine and referral. However, the connection between the existing medical alliances is still not close enough, and the support of large hospitals is often carried out in the form of point-to-point single diagnosis and treatment, rather than the reform and learning of the entire system, which is easy to become a "temporary help" that "treats the symptoms but not the root cause".
In 2021, at the beginning of the 14th Five-Year Plan, the "14th Five-Year Plan" high-quality and efficient medical and health service system construction implementation plan proposed that the central budget investment will focus on supporting the construction of national medical centers and regional medical centers, and promote the expansion and sinking of provincial high-quality medical resources.
Comprehensively promote the construction of community hospitals and grassroots medical and health institutions, and strive to realize that every prefecture and city has a third-class hospital, and county-level hospitals that serve more than 1 million people have county-level hospitals that reach the hardware facilities and service capacity of urban tertiary hospitals.
At the moment when the big wave of the top three hit, for the county hospital, to be or not to be,that's a question.
Curator: Leu.| Title image source: Tuworm Creative
Author: Guan Lin