- Email: [email protected]
Chinese perspective of the role of primary care in cancer control
Comment
*Carin A Uyl-de Groot, Werner B F Brouwer, Jan M de Maeseneer, Jaap Verweij
2
Institute for Medical Technology Assessment, and Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands (CAU-dG, WBFB); Department of Family Medicine and Primary Health Care, Ghent University, University Hospital, Gent, Belgium (JMdM); and Erasmus MC, Rotterdam, Netherlands (JV) [email protected]
3
CAU-dG reports grants from Boehringer Ingelheim, GSK, Janssen-Cilag, Astellas, Roche, Therakos, Amgen, Gilead, Merck, Sanofi, Bayer, the Dutch government, and the European Union outside the submitted work. WBFB reports grants from AstraZeneca, GlaxoSmithKline, Janssen, MSD, Novartis, Pfizer, the Dutch Government, and the European Union outside the submitted work. JV reports personal fees from Sarcoma Alliance through Research and Collaboration, GSK, Lilly, Eisai, Sanofi, Bayer, Boehringer Ingelheim, Synthon, Abbvie, Merck-Serono, XBiotech, Cancer Research UK, and Sotio outside the submitted work. JMdM declares no competing interests.
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Uyl-de Groot CA, de Vries EGE, Verweij J, Sullivan R. Dispelling the myths around cancer care delivery: it’s not all about costs. J Cancer Policy 2014; 2: 22–29. The Health Foundation. Summit report: leading the way to shared decision making. February 2012. http://www.health.org.uk/sites/default/files/ LeadingTheWayToSharedDecisionMaking.pdf (accessed Sept 2, 2015). de Maeseneer JM, van Driel ML, Green LA, van Weel C. The need for research in primary care. Lancet 2003; 362: 1314–19. de Maeseneer JM, Boeckxstaens P. Multimorbidity, goal-oriented care, and equity. Br J Gen Pract 2012; 62: e522–24. de Maeseneer J, Roberts RG, Demarzo M, et al. Tackling NCDs: a different approach is needed. Lancet 2012, 379; 1860–61. EXPH (EXpert Panel on effective ways of investing in Health). Definition of a frame of reference in relation to primary care with a special emphasis on financing systems and referral systems. Brussels: European Commission, 2014. http://ec.europa.eu/health/expert_panel/opinions/docs/004_ definitionprimarycare_en.pdf (accessed Aug 28, 2015). Luengo-Fernandez R, Leal J, Gray A, Sullivan R. Economic burden of cancer across the European Union: a population-based cost analysis. Lancet Oncol 2013; 14: 1165–74. Raphael C, Ahrens J, Fowler N. Financing end-of-life care in the USA. R Soc Med 2001; 94: 458–61.
Rubin G, Berendsen A, Crawford SM, et al. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16: 1231–72.
In The Lancet Oncology Commission,1 Greg Rubin and colleagues describe the expanding role of primary care in cancer control. I agree with the authors that primary care has an increasingly important role for patients throughout their journey. The Commission gives valuable perspectives for further development of primary cancer care. According to China’s Aging Society and the Pension Insurance Development Report in 2014,2 the proportion of the population in China aged 65 years or older rose from 9·4% in 2012 to 9·7% in 2013. Cancer is one of many diseases of the elderly, and the number of patients with cancer will continue to increase. Indeed in 2014, the National Central Cancer Registry reported cancer incidence had reached 250·28 per 100 000 people and mortality was 156·83 per 100 000 people in mainland China.3 Because of improved treatment options, cancer has become a chronic disease that is nonetheless difficult to cure and that requires long-term management. Many patients with cancer seek medical assistance first in local hospitals; thus, the development of medical facilities at the city, county, and community levels is important in China. Therefore, primary care physicians (PCPs) would be an important part of cancer control. At present, the work of community health care is best done in Shanghai, China, where such health-care services were built at a scale of one per 10 000–20 000 people. By relieving outpatient examination fees for community hospitals www.thelancet.com/oncology Vol 16 September 2015
and controlling medical service fees for inpatients and outpatients of these hospitals, and by implementing programmes such as the Shanghai community health mutual help programme, more than 80% of patients with common or chronic diseases go to community hospitals as their first point of contact. There has also been substantial progress in the construction of community health-care systems in other areas of China, and such systems will continue to evolve in the future. The role of community care in cancer control includes prevention, screening, diagnosis, treatment, survivorship care, and palliative care. In the past 10 years, several public health programmes of cancer screening, early diagnosis, and treatment were led by China’s National Health and Family Planning Commission. In rural areas, these projects for breast and cervical cancers were all done in local maternal and child care service centres. Many patients with cancer-related symptoms initially go to local county or community hospitals, before being referred to large cancer centres or comprehensive hospitals to receive a final diagnosis and treatment. But management of complications, rehabilitation, supportive care, and follow-up are still provided in county or community hospitals. Most patients with end-stage cancer receive palliative care in these hospitals too, and Chinese traditional medicine also plays an important part in reducing side-effects and improving quality of life.
Brooks/Brown/Science Photo Library
Chinese perspective of the role of primary care in cancer control
See The Lancet Oncology Commission page 1231
1227
Comment
A series of measures have been undertaken to promote the development of primary care in China. The Chinese Society of General Practice was founded in 1993—a first step towards the recognition of general medical practice in China. The basic framework of the primary care medical education system was constructed in 2000 and a fairly comprehensive general medical education system was in place by 2010 to meet the needs of health reform and of community health services. China’s national medical insurance system, covering the whole country, was established in 2008 and is broadly divided into three types: basic medical insurance for urban employees, basic medical insurance for urban residents, and rural cooperative medical insurance for farmers. Other people who live in rural areas are entitled to the same basic medical insurance as urban employees. To further improve the medical insurance system and reduce the economic burden for people who have serious diseases such as cancer, the catastrophic medical insurance system was set up in 2012 and is now available in more than 90% of cities and counties as of June, 2015. Therefore, patients who have serious diseases can be reimbursed for more than 50% of the additional cost after the original reimbursement. All of these insurance systems are accepted at all levels of hospitals to ensure the referral channels are unimpeded. The Key Tasks of Health Reform in 2015 of the State Council report4 stressed that the Chinese Government would need
to continue to support construction of the community health-service system and enhance the comprehensive ability of community health services. Furthermore, to improve the medical capacity of PCPs, standardised training of junior doctors would need to be fully implemented, and about 50 000 new junior physicians will receive such training in 2015. With an increased emphasis on cancer control services in community hospitals, the diagnosis and treatment of patients should be improved. The key findings of The Lancet Oncology Commission1 provide valuable information to help to improve the health-care system in China. Yuankai Shi National Cancer Center; Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing 100021, China [email protected] I declare no competing interests. 1 2
3 4
Rubin G, Berendsen A, Crawford SM, et al. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16: 1231–72. Aging Society and the Pension Insurance Development report. 2014. http://www.cnki.net/KCMS/detail/detail.aspx?QueryID=0&CurRec=1&recid =&filename=JJZK2015Z1017&dbname=CJFDLAST2015&dbcode=CJFQ&pr =&urlid=&yx=&v=MjY1MDBGckNVUkwrZmJ1WnRGeXpnVTc3Qkx5ZlJaYkc 0SDlTbXJvOUVZNFI4ZVgxTHV4WVM3RGgxVDNxVHJXTTE= (accessed Feb 23, 2015; in Chinese). Chen W, Zheng R, Zeng H, Zhang S, He J. Annual report on status of cancer in China, 2011. Chin J Cancer Res 2015; 27: 2–12 The Key Tasks of Health Reform in 2015 of the State Council. April 26, 2015. http://www.gov.cn/zhengce/content/2015-05/09/content_9716. htm (accessed May 5, 2015).
Tek Image/Science Photo Library
Paying for the expanding role of primary care in cancer control
See The Lancet Oncology Commission page 1231
1228
Advances in cancer detection and treatment pose a challenge to traditional cancer services focused on the acute delivery of specialist care. In The Lancet Oncology Commission,1 Greg Rubin and colleagues set out an exhaustive charter for the role of primary care services, and the primary care physician (PCP). The authors suggest 18 action points for a greater role for the PCP from detection to palliation. Effective PCP involvement in cancer care will depend on the identification of appropriate PCP roles and the development of skills, which the Commission does address, and also on the provision of the right financial incentives, which the Commission mentions only briefly. At a fundamental level, how PCPs are paid affects the type and volume of care they provide. Australia, as
in the UK and several other European countries, has a strong primary care system with a gatekeeping role. Unlike the UK, Australian PCPs are funded on a fee-forservice basis, and patients are not registered to specific PCPs or primary care organisations.2 Incentive payments for PCPs have been targeted to specific interventions such as cervical screening.3 But if each specific cancerrelated behaviour outlined in the Commission were to attract its own payment, the funding system would soon become overwhelmingly complex. In general, a reliance on fee-for-service provides an incentive for PCPs to increase the volume of care and to generate revenue, rather than to provide continuity and integration of patient care. This is becoming an increasing challenge with the growing incidence of complex and www.thelancet.com/oncology Vol 16 September 2015
*Carin A Uyl-de Groot, Werner B F Brouwer, Jan M de Maeseneer, Jaap Verweij
2
Institute for Medical Technology Assessment, and Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands (CAU-dG, WBFB); Department of Family Medicine and Primary Health Care, Ghent University, University Hospital, Gent, Belgium (JMdM); and Erasmus MC, Rotterdam, Netherlands (JV) [email protected]
3
CAU-dG reports grants from Boehringer Ingelheim, GSK, Janssen-Cilag, Astellas, Roche, Therakos, Amgen, Gilead, Merck, Sanofi, Bayer, the Dutch government, and the European Union outside the submitted work. WBFB reports grants from AstraZeneca, GlaxoSmithKline, Janssen, MSD, Novartis, Pfizer, the Dutch Government, and the European Union outside the submitted work. JV reports personal fees from Sarcoma Alliance through Research and Collaboration, GSK, Lilly, Eisai, Sanofi, Bayer, Boehringer Ingelheim, Synthon, Abbvie, Merck-Serono, XBiotech, Cancer Research UK, and Sotio outside the submitted work. JMdM declares no competing interests.
7
1
4 5 6
8
9
Uyl-de Groot CA, de Vries EGE, Verweij J, Sullivan R. Dispelling the myths around cancer care delivery: it’s not all about costs. J Cancer Policy 2014; 2: 22–29. The Health Foundation. Summit report: leading the way to shared decision making. February 2012. http://www.health.org.uk/sites/default/files/ LeadingTheWayToSharedDecisionMaking.pdf (accessed Sept 2, 2015). de Maeseneer JM, van Driel ML, Green LA, van Weel C. The need for research in primary care. Lancet 2003; 362: 1314–19. de Maeseneer JM, Boeckxstaens P. Multimorbidity, goal-oriented care, and equity. Br J Gen Pract 2012; 62: e522–24. de Maeseneer J, Roberts RG, Demarzo M, et al. Tackling NCDs: a different approach is needed. Lancet 2012, 379; 1860–61. EXPH (EXpert Panel on effective ways of investing in Health). Definition of a frame of reference in relation to primary care with a special emphasis on financing systems and referral systems. Brussels: European Commission, 2014. http://ec.europa.eu/health/expert_panel/opinions/docs/004_ definitionprimarycare_en.pdf (accessed Aug 28, 2015). Luengo-Fernandez R, Leal J, Gray A, Sullivan R. Economic burden of cancer across the European Union: a population-based cost analysis. Lancet Oncol 2013; 14: 1165–74. Raphael C, Ahrens J, Fowler N. Financing end-of-life care in the USA. R Soc Med 2001; 94: 458–61.
Rubin G, Berendsen A, Crawford SM, et al. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16: 1231–72.
In The Lancet Oncology Commission,1 Greg Rubin and colleagues describe the expanding role of primary care in cancer control. I agree with the authors that primary care has an increasingly important role for patients throughout their journey. The Commission gives valuable perspectives for further development of primary cancer care. According to China’s Aging Society and the Pension Insurance Development Report in 2014,2 the proportion of the population in China aged 65 years or older rose from 9·4% in 2012 to 9·7% in 2013. Cancer is one of many diseases of the elderly, and the number of patients with cancer will continue to increase. Indeed in 2014, the National Central Cancer Registry reported cancer incidence had reached 250·28 per 100 000 people and mortality was 156·83 per 100 000 people in mainland China.3 Because of improved treatment options, cancer has become a chronic disease that is nonetheless difficult to cure and that requires long-term management. Many patients with cancer seek medical assistance first in local hospitals; thus, the development of medical facilities at the city, county, and community levels is important in China. Therefore, primary care physicians (PCPs) would be an important part of cancer control. At present, the work of community health care is best done in Shanghai, China, where such health-care services were built at a scale of one per 10 000–20 000 people. By relieving outpatient examination fees for community hospitals www.thelancet.com/oncology Vol 16 September 2015
and controlling medical service fees for inpatients and outpatients of these hospitals, and by implementing programmes such as the Shanghai community health mutual help programme, more than 80% of patients with common or chronic diseases go to community hospitals as their first point of contact. There has also been substantial progress in the construction of community health-care systems in other areas of China, and such systems will continue to evolve in the future. The role of community care in cancer control includes prevention, screening, diagnosis, treatment, survivorship care, and palliative care. In the past 10 years, several public health programmes of cancer screening, early diagnosis, and treatment were led by China’s National Health and Family Planning Commission. In rural areas, these projects for breast and cervical cancers were all done in local maternal and child care service centres. Many patients with cancer-related symptoms initially go to local county or community hospitals, before being referred to large cancer centres or comprehensive hospitals to receive a final diagnosis and treatment. But management of complications, rehabilitation, supportive care, and follow-up are still provided in county or community hospitals. Most patients with end-stage cancer receive palliative care in these hospitals too, and Chinese traditional medicine also plays an important part in reducing side-effects and improving quality of life.
Brooks/Brown/Science Photo Library
Chinese perspective of the role of primary care in cancer control
See The Lancet Oncology Commission page 1231
1227
Comment
A series of measures have been undertaken to promote the development of primary care in China. The Chinese Society of General Practice was founded in 1993—a first step towards the recognition of general medical practice in China. The basic framework of the primary care medical education system was constructed in 2000 and a fairly comprehensive general medical education system was in place by 2010 to meet the needs of health reform and of community health services. China’s national medical insurance system, covering the whole country, was established in 2008 and is broadly divided into three types: basic medical insurance for urban employees, basic medical insurance for urban residents, and rural cooperative medical insurance for farmers. Other people who live in rural areas are entitled to the same basic medical insurance as urban employees. To further improve the medical insurance system and reduce the economic burden for people who have serious diseases such as cancer, the catastrophic medical insurance system was set up in 2012 and is now available in more than 90% of cities and counties as of June, 2015. Therefore, patients who have serious diseases can be reimbursed for more than 50% of the additional cost after the original reimbursement. All of these insurance systems are accepted at all levels of hospitals to ensure the referral channels are unimpeded. The Key Tasks of Health Reform in 2015 of the State Council report4 stressed that the Chinese Government would need
to continue to support construction of the community health-service system and enhance the comprehensive ability of community health services. Furthermore, to improve the medical capacity of PCPs, standardised training of junior doctors would need to be fully implemented, and about 50 000 new junior physicians will receive such training in 2015. With an increased emphasis on cancer control services in community hospitals, the diagnosis and treatment of patients should be improved. The key findings of The Lancet Oncology Commission1 provide valuable information to help to improve the health-care system in China. Yuankai Shi National Cancer Center; Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing 100021, China [email protected] I declare no competing interests. 1 2
3 4
Rubin G, Berendsen A, Crawford SM, et al. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16: 1231–72. Aging Society and the Pension Insurance Development report. 2014. http://www.cnki.net/KCMS/detail/detail.aspx?QueryID=0&CurRec=1&recid =&filename=JJZK2015Z1017&dbname=CJFDLAST2015&dbcode=CJFQ&pr =&urlid=&yx=&v=MjY1MDBGckNVUkwrZmJ1WnRGeXpnVTc3Qkx5ZlJaYkc 0SDlTbXJvOUVZNFI4ZVgxTHV4WVM3RGgxVDNxVHJXTTE= (accessed Feb 23, 2015; in Chinese). Chen W, Zheng R, Zeng H, Zhang S, He J. Annual report on status of cancer in China, 2011. Chin J Cancer Res 2015; 27: 2–12 The Key Tasks of Health Reform in 2015 of the State Council. April 26, 2015. http://www.gov.cn/zhengce/content/2015-05/09/content_9716. htm (accessed May 5, 2015).
Tek Image/Science Photo Library
Paying for the expanding role of primary care in cancer control
See The Lancet Oncology Commission page 1231
1228
Advances in cancer detection and treatment pose a challenge to traditional cancer services focused on the acute delivery of specialist care. In The Lancet Oncology Commission,1 Greg Rubin and colleagues set out an exhaustive charter for the role of primary care services, and the primary care physician (PCP). The authors suggest 18 action points for a greater role for the PCP from detection to palliation. Effective PCP involvement in cancer care will depend on the identification of appropriate PCP roles and the development of skills, which the Commission does address, and also on the provision of the right financial incentives, which the Commission mentions only briefly. At a fundamental level, how PCPs are paid affects the type and volume of care they provide. Australia, as
in the UK and several other European countries, has a strong primary care system with a gatekeeping role. Unlike the UK, Australian PCPs are funded on a fee-forservice basis, and patients are not registered to specific PCPs or primary care organisations.2 Incentive payments for PCPs have been targeted to specific interventions such as cervical screening.3 But if each specific cancerrelated behaviour outlined in the Commission were to attract its own payment, the funding system would soon become overwhelmingly complex. In general, a reliance on fee-for-service provides an incentive for PCPs to increase the volume of care and to generate revenue, rather than to provide continuity and integration of patient care. This is becoming an increasing challenge with the growing incidence of complex and www.thelancet.com/oncology Vol 16 September 2015