Recently, the National Health Commission and other 10 departments jointly issued the "Guiding Opinions on Comprehensively Promoting the Construction of a Close-knit County Medical and Health Community" (hereinafter referred to as the "Guiding Opinions"), putting forward 20 key tasks and requirements from five aspects, emphasizing the integration of urban and rural areas, townships and villages, counties and townships, and rural areas, and vigorously improve the capacity of primary medical and health services. By the end of 2027, the close-knit county-level medical community will basically achieve full coverage.
The "Guiding Opinions" proposes to establish a county-level medical community led by county-level hospitals and composed of several other county-level medical and health institutions, township health centers, and community health service centers according to geographical location, service population, and layout of existing medical and health institutions. The number of establishments shall be determined by the local government in light of actual conditions, and counties with a large population or area may form more than two county-level medical communities. The lead hospital is generally a non-profit general hospital or a traditional Chinese medicine hospital of the second level or above. Encourage and guide social forces to run medical institutions to join the county-level medical community.
The "Guiding Opinions" put forward specific requirements for improving the overall service capacity of county-level medical communities from five aspects: promoting resource service sharing, improving major epidemic response and medical emergency response capabilities, expanding family doctor contract services, innovating medical and prevention integration services, and improving traditional Chinese medicine service capabilities. Among them, it is required to coordinate the establishment of five resource sharing centers in the county, including medical examination, medical imaging, electrocardiogram diagnosis, pathological diagnosis, and disinfection supply, and coordinate the establishment of five major clinical service centers in the county, including tumor prevention and treatment, chronic disease management, minimally invasive intervention, anesthesia and pain diagnosis and treatment, and intensive care.
According to the "Guiding Opinions", secondary and tertiary hospitals should improve the service capacity and management level of the county-level medical community through expert dispatch, specialist co-construction, clinical teaching, remote collaboration, scientific research and project collaboration. The leading hospital should send clinical and management personnel to the township (street) all year round to help solve grassroots problems and carry out itinerant medical treatment for the countryside. Qualified public village clinics will be gradually converted into village-level medical service points extended by township health centers, and unified management of administration, personnel, business, drugs, finance, and performance will be implemented.
The "Guiding Opinions" require that by the end of June 2024, the construction of a close-knit county-level medical community will be comprehensively promoted at the provincial level, and by the end of 2025, more than 90% of the counties (cities) in the country will be basically built into a close-knit county-level medical community with reasonable layout, unified management of personnel, property and property, clear rights and responsibilities, efficient operation, division of labor and cooperation, continuous service, and information sharing.
Official interpretation
1. What is the background and significance of the issuance of the Guiding Opinions?
Promoting the construction of county medical community is a key task emphasized by General Secretary Xi Jinping many times, a powerful starting point for promoting healthy China and the construction of a hierarchical diagnosis and treatment system, and an important measure for deepening medical reform. In recent years, the mainland's medical and health service capacity has been improved as a whole, and the level of public health protection has been continuously improved. However, on the whole, the total supply of high-quality medical resources on the mainland is still insufficient, the structure is irrational, and the quality and efficiency have not been fully reflected; in particular, the capacity of grassroots medical services in some areas has weakened, and there is still a gap between the people's expectation that they can "see a good doctor" nearby. To this end, in 2017, the General Office of the State Council issued the "Guiding Opinions on Promoting the Construction and Development of Medical Complexes", which clarified that medical and medical communities should be established mainly at the county level to promote the flow of high-quality medical resources to the grassroots and remote poor areas.
In 2019, the National Health Commission launched the pilot work of building a close-knit county-level medical and health community, focusing on the construction of a community of responsibility, management, service and interests, so as to better realize the sinking of resources and the improvement of the overall capacity of the county. Since the launch of the pilot, three provinces, Shanxi, Zhejiang and Xinjiang, have been identified as pilot provinces, and a total of 828 counties in 551 counties (districts and cities) in other provinces have been identified as pilot counties. All localities have actively explored and made positive progress and results in optimizing the allocation of medical and health resources at the county level, improving the service capacity of the county, improving the medical experience of the masses, and improving the management system and operation mechanism. Since 2020, the No. 1 Document of the Central Committee has put forward requirements for promoting the construction of a close-knit county-level medical community for four consecutive years, and the party committees and governments at all levels and relevant departments have gradually unified their understanding of the construction of county-level medical communities, and the degree of attention and work intensity have been significantly strengthened.
At the beginning of 2023, the General Office of the Central Committee of the Communist Party of China and the General Office of the State Council successively issued the "Opinions on Further Deepening Reform and Promoting the Healthy Development of the Rural Medical and Health System" and "Opinions on Further Improving the Medical and Health Service System", proposing to accelerate the construction of a close-knit county-level medical community. The close-knit county-level medical community is a systematic reshaping of medical and health resources in the county and an innovation of the health governance system, which requires not only the leadership and support of local party committees and governments, but also the coordination and close cooperation between departments. Since the beginning of the year, the National Health Commission, together with the Central Planning Office and the National Development and Reform Commission, have jointly studied and drafted the Guiding Opinions. The issuance of the "Guiding Opinions" marks that the construction of a compact county-level medical community has entered the stage of comprehensive promotion from the pilot stage, and provides a guide for all localities to standardize and steadily carry out the construction of a close-knit county-level medical community.
2. What are the framework and features of the Guiding Opinions?
The "Guiding Opinions" adhere to the combination of top-level design and local practice, and elevate local good experiences and good practices to policy measures; persist in adapting measures to local conditions and seeking progress while maintaining stability, and do not engage in "one-size-fits-all" to leave room for local governments to further refine and improve measures; adhere to the system concept and goal-oriented and problem-oriented, emphasizing the integration of urban and rural areas, townships and villages, counties and townships, and rural areas, and strive to solve the difficulties and blockages encountered in the process of carrying out pilot projects in various localities. The "Guiding Opinions" put forward the connotation of a close-knit county-level medical community, that is, focusing on the goal of "county-level strength, township-level activity, village-level stability, upper and lower linkage, and information communication", through the systematic reshaping of the medical and health system and the integration and optimization of medical and health resources, to promote the integration of urban and rural areas, townships and villages, county and township, and rural integration, accelerate the construction of a compact county-level medical community, and vigorously improve the capacity of primary medical and health services, so that the masses can enjoy more equitable and accessible, systematic and continuous prevention, treatment, rehabilitation, and so on. Health promotion and other health services provide a strong guarantee for the construction of a healthy China and rural revitalization.
The "Guiding Opinions" put forward 20 key tasks and requirements from 5 aspects, and made clear provisions on the external management, internal operation, improvement of services, and support policies of the county-level medical community. The "Guiding Opinions" emphasize the policy orientation of the construction of the medical community, that is, "strengthen the county and the grassroots", and promote the realization of the solution of general diseases in cities and counties, and the solution of daily diseases at the grassroots level. The work path is clarified, which is to build the "four communities" of responsibility, management, service and interests, and enhance the endogenous power and sustainability of the construction of the medical community. The development requirements are put forward, that is, "close-knit, homogeneous, cost control, division of labor, and health protection" to ensure the steady and far-reaching construction of the medical community.
3. What are the overall requirements and goals for comprehensively promoting the construction of a close-knit county-level medical community?
The "Guiding Opinions" adhere to the guidance of Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era, fully implement the spirit of the 20th National Congress of the Party, implement the party's health and health work guidelines in the new era, deepen the "three medicines" linkage reform, and require that around the goal of "strong at the county level, active at the township level, stable at the village level, upper and lower linkages, and information communication", through the systematic reshaping of the medical and health system and the integration and optimization of medical and health resources, promote the integration of urban belt and township, township belt village and county and township, Rural integration, accelerate the construction of a close-knit county-level medical community, vigorously improve the capacity of primary medical and health services, so that the masses can enjoy more equitable and accessible, systematic and continuous health services such as prevention, treatment, rehabilitation, and health promotion nearby, and provide a strong guarantee for the construction of a healthy China and rural revitalization.
By the end of June 2024, the construction of county-level medical communities will be comprehensively promoted at the provincial level, and by the end of 2025, significant progress will be made in the construction of county-level medical communities, and more than 90% of the counties (cities) in the country will be basically built into close-knit county-level medical communities with reasonable layout, unified management of personnel, financial and material resources, clear rights and responsibilities, efficient operation, division of labor and cooperation, continuous services, and information sharing, and by 2027, close-knit county-level medical communities will basically achieve full coverage.
4. How to understand the scientific construction of county-level medical community proposed in the "Guiding Opinions"?
On the basis of summarizing the experience of the pilot in the early stage, the "Guiding Opinions" proposes to establish a county-level medical community led by county-level hospitals and composed of several other county-level medical and health institutions, township health centers, and community health service centers according to geographical location, service population, and layout of existing medical and health institutions. There is no "one-size-fits-all" approach to the number of formations, but can be determined by the localities in the light of actual conditions, leaving a large space for the localities to be independent. For counties with a large population or large area, more than two county-level medical communities can be formed. The leading hospitals of county-level medical communities are generally non-profit general hospitals or traditional Chinese medicine hospitals above the second level. In accordance with the principle of voluntariness, with the focus on homogeneous management of business and strengthening rural services, encourage and guide social forces to run medical institutions to join the county-level medical community.
5. What are the requirements of the "Guiding Opinions" for strengthening the linkage between the upper and lower levels and the coordination of medical prevention in the construction of a close-knit county-level medical community?
In terms of urban-rural linkage, the "Guiding Opinions" emphasize deepening the work of urban support for rural areas, and second- and third-level hospitals should improve the service capacity and management level of county-level medical communities through expert dispatch, specialist co-construction, clinical teaching, remote collaboration, scientific research and project collaboration.
In terms of counties leading townships, the "Guiding Opinions" proposes that the leading hospitals should send clinical and management talents to townships (streets) all year round to help solve grassroots problems and carry out roving medical treatment for rural areas. Promote the rational flow of personnel, give priority to ensuring the employment needs of primary medical and health institutions, and ensure that each township health center (community health service center) has at least one attending physician or above in the leading hospital to serve all year round.
In terms of townships and villages, the "Guiding Opinions" proposes to gradually transform eligible public village clinics into village-level medical service points extended by township health centers, and implement unified management of administration, personnel, business, drugs, finance, and performance. For other types of village clinics, we will continue to deepen the integrated management of rural health.
In terms of medical and prevention coordination, the "Guiding Opinions" proposes to establish and improve professional public health institutions to carry out technical guidance and business training for county-level medical communities, send personnel to serve in townships and towns, and strengthen medical and prevention coordination and resource information sharing. Explore the participation of professional public health institutions in the management and service of county-level medical communities.
6. What are the specific requirements of the "Guiding Opinions" in regulating the internal operation and management of county-level medical communities?
The "Guiding Opinions" put forward task requirements for standardizing the internal operation and management of county-level medical communities from four aspects.
The first is to improve the internal decision-making mechanism. It is required to formulate the charter of the county-level medical community, clarify the organizational structure, and improve the decision-making system. Strengthen the construction of party organizations within the county-level medical community, and give full play to the role of party committees in guiding the direction, managing the overall situation, making decisions, promoting reform, and ensuring implementation. Select and match the responsible personnel of the county-level medical community, and the responsible personnel must have representatives of primary medical and health institutions.
The second is to strengthen performance appraisal. All localities are required to clarify the annual task objectives and performance appraisal indicators of the county-level medical community, guide resources to sink to the countryside, and the assessment results are linked to the public health service subsidy, medical insurance fund payment, total performance salary approval, and the salary, appointment and dismissal, rewards and punishments of responsible personnel. Establish and improve the internal assessment mechanism, and the assessment indicators are inclined to the sinking of resources, the dispatch of patrols, the signing of family doctors, and cost control, and the establishment of a long-term incentive mechanism.
The third is to optimize internal management. It is required to gradually realize the unified management of internal administration, personnel, finance, business, medication, information, and logistics of the county-level medical community. Integrate the resources of the county-level medical community, and reasonably establish five management centers, including human resources, financial management, medical quality control, medical insurance management, and information and data.
Fourth, improve the quality of management services. It is required to unify the rules and regulations and technical specifications, personnel training, quality control and other standards within the county-level medical community, strengthen the medical quality and safety management of the county-level medical community, improve the workflow and standards such as ward rounds, medical case management, prescription reviews, and inter-agency referrals, and strengthen the monitoring and evaluation of the quality of inspection and disease diagnosis.
7. What are the tasks and requirements of the "Guiding Opinions" in improving the capacity of medical and health services at the county level?
The "Guiding Opinions" put forward specific requirements for improving the overall service capacity of county-level medical communities from five aspects.
The first is to promote the sharing of resources and services. Coordinate the establishment of five resource sharing centers in the county, including medical examination, medical imaging, electrocardiogram diagnosis, pathological diagnosis, and disinfection supply, and coordinate the establishment of five major clinical service centers in the county, including tumor prevention and treatment, chronic disease management, minimally invasive intervention, anesthesia and pain diagnosis and treatment, and intensive care, so as to improve the efficiency of resource allocation and use, and enhance service capabilities.
The second is to improve the capacity to respond to major epidemics and medical emergencies. It is required to improve the monitoring and early warning mechanism for infectious diseases in the county-level medical community, improve the treatment mechanism for major epidemics at different levels and levels, strengthen the construction of the county-level medical emergency system, strengthen the guidance of leading hospitals to the grassroots, and strengthen the medical resources and material reserves for major epidemics.
The third is to expand the contracted service of family doctors. It is required to rely on basic medical and health institutions to carry out contracted services for family doctors, and expand contracted services for the general population and key populations.
Fourth, innovative medical and prevention integration services. It is required to carry out integrated services such as disease prevention, screening, diagnosis and treatment, nursing, and rehabilitation around key groups such as patients with chronic diseases, the elderly, children, pregnant women, and patients with major infectious diseases.
Fifth, improve the service capacity of traditional Chinese medicine. The county-level traditional Chinese medicine hospitals are required to coordinate the county's traditional Chinese medicine service resources, and give full play to the leading role of county-level traditional Chinese medicine medical treatment, preventive health care, characteristic rehabilitation, talent training, appropriate technology promotion and traditional Chinese medicine health education.
8. What specific measures does the "Guiding Opinions" put forward to support county-level medical communities in terms of investment guarantee, personnel establishment and salary?
In terms of investment guarantee, the "Guiding Opinions" emphasize the implementation of the government's responsibility for investment guarantee, and the development and construction expenditures such as the capital construction and equipment purchase of government-run primary medical and health institutions shall be arranged in full by local governments in accordance with the development and construction plan; and the operating costs such as personnel expenses and operating expenses shall be compensated through service charges and government subsidies. The central government provides support to rural medical and health institutions through subsidies for basic public health services and basic drug systems. The central budget has invested more support for eligible projects within the county-level medical community. The new fiscal health expenditure of local governments should be appropriately tilted towards the primary medical and health institutions within the county-level medical community.
In terms of personnel establishment, the "Guiding Opinions" proposes to give more autonomy to county-level medical communities in terms of establishment and use, personnel recruitment, personnel arrangement, performance appraisal, and professional title evaluation. On the basis of the separate approval of the establishment of public medical and health institutions within the county-level medical community, more attention should be paid to the overall use of personnel, and according to the needs of the post, the county should be managed by the township and the township should be hired by the village. With the county-level medical community as a unit, make full use of the number of professional and technical posts, and appropriately increase the proportion of intermediate and senior professional and technical posts in primary medical and health institutions.
In terms of salary, the "Guiding Opinions" emphasize the implementation of the "two allows" requirements, coordinate and balance the level of performance-based wages at the county and township levels, and reasonably regulate and control the income gap between various types of medical and health institutions at all levels. Encourage the implementation of an annual salary system for the heads of medical and health institutions within the county-level medical community.
9. What specific measures does the "Guiding Opinions" put forward for medical insurance to support county-level medical communities?
The first is to improve the medical insurance payment policy. The "Guiding Opinions" clearly implement the total payment of medical insurance funds for the close-knit county-level medical community, strengthen the assessment of the growth rate of medical expenses, the proportion of medical insurance reimbursement, the rate of primary medical treatment, the proportion of fund expenditure in the county, and the proportion of the medical insurance fund of the primary medical and health institutions in the county, improve the surplus retention mechanism, and use the surplus funds as the business income of the county-level medical community, and improve the reasonable over-expenditure sharing mechanism. For some diseases suitable for grassroots development, gradually explore different levels of medical institutions to pay for the same disease. Continue to implement differentiated payment policies for different levels of medical institutions, and continuously calculate the minimum payment line for referred inpatients who meet the requirements.
The second is to strengthen the coordination of medical security policies. The "Guiding Opinions" emphasize that when all localities implement dynamic adjustment of medical service prices, they should coordinate and support the development of rural medical and health institutions. Implement the policy of general diagnosis and treatment fees, and where conditions permit, adjust the general diagnosis and treatment fees of township health centers, village clinics, and other primary medical and health institutions. Appropriate health services in rural areas have been added to the medical insurance reimbursement catalogue, and the proportion of service income of rural medical and health institutions has been gradually increased. For medical service projects with a high degree of homogeneity, such as dressing change, injection, infusion, and blood collection, the specific scope can be clarified, and the same price in the same city at the county level can be gradually implemented. Implement the "Internet +" medical service price policy, and promote the extension of medical services such as Internet diagnosis and treatment and remote consultation to the grassroots level.
10. How to implement the tasks and requirements set forth in the Guiding Opinions?
The first is to strengthen organizational promotion. The administrative departments of health play a leading and coordinating role, and relevant departments cooperate closely. All localities are to establish and complete working mechanisms, formulate timetables and roadmaps in light of actual conditions, and formulate relevant supporting documents or implementation rules.
The second is to strengthen monitoring and evaluation. Highlight the continuous improvement of the proportion of rural diagnosis and treatment volume, improve the monitoring and evaluation index system for the construction of county-level medical communities, carry out annual monitoring and evaluation, and strengthen data analysis and sharing.
The third is to strengthen publicity and guidance. Deeply summarize and promote the experience and practices of the construction of a close-knit county-level medical community, and publicize the progress and effectiveness and advanced models. Strengthen the guidance of public opinion, respond to social concerns in a timely manner, mobilize the enthusiasm and initiative of all parties, and create a good environment and atmosphere for the construction of county-level medical communities.
Full text link: Guiding Opinions on Comprehensively Promoting the Construction of a Close-knit County-level Medical and Health Community
编辑 | 尹蓁 责编 | 张秀丽
Source | The official website of the National Health Commission
Produced by the Guangdong Health Online all-media team