Policy practice Xin Wang et al. People-centred care in urban China and collaboration across tiers.Trust in Luohu was also important for provid- health-care expenditure when calculat- needs to be built for collaboration be- ing the capacity to support integrated ing global budgets for hospital groups, tween institutions in other health-care care through the gatekeeper strategy to avoid budget deficits in the first year systems. During the period 2015-2017,the num- Changing patient behaviour ber of general practitioners in the group increased from 89 to 194,based on offer Next steps The second challenge was how to change ing higher salaries and training in task- There are two remaining steps in the the behaviour of the population towards shifting for some specialists.In 2017, application of the Luohu model.First, using community health stations as the there were 3.02 general practitioners several strategies have not yet been first point of contact,rather than going per 10000 residents in Luohu,compared implemented (Table 1),including risk to hospitals.In the Luohu model,four with an average of 1.38 per 10000 for stratification,individual care plans for strategies were used to overcome this the entire country.2 Policymakers in patients,integrated clinical pathways cultural challenge.The first strategy was other health-care systems might con- for care integration,decision support capacity-building in community health sider general practitioner training of and certification.The Luohu hospital stations.Technical assistance from some specialists and task-shifting from group is preparing to implement a risk district-level hospitals contributed to the general practitioners to experienced stratification exercise based on disease improvement of care quality in commu nurses and public health physicians to burden."Once high-risk patients have nity health stations.The second strategy fill the general practitioner gaps in the been identified,individual care plans was people-centred care in community short term. will be made.Clinical pathways are be- health stations.For example,in response to the needs ofelderly patients confined Reducing costs ing created to standardize the treatment and referral pathways between provid- to bed,the community health stations The third challenge was how to avoid ers and to integrate care and support provided home visits to avoid unneces- budget deficits in the first year.The decision-making.Second,monitoring sary hospital admissions and maintain goal of lower financial burdens has not and evaluation is necessary to determine patients at home,while reducing the been achieved in the first two years the effectiveness of the Luohu model burden of care on family members. of the Luohu model.The 2016 global over time.Despite the new self-evalua- The third strategy was ensuring ad- budget of the Luohu model was given tion system,more indicators related to equate supplies of common drugs in by the total cost of health insurance for people-centred care,population health community health stations.According registered residents in the previous year, and financial burden over the long-term to a study of 22 city-level hospitals in multiplied by the average growth rate are required.Although residents'satis- Beijing,one-third of patients attended of the health insurance fund in 2016 faction with health care in Luohu district hospitals solely to receive drugs(num- However,the average cost of integrated was high,their experience of integrated bers not stated).22 In the Luohu model, care per registered resident in the group care was not a focus of the present study, district-level hospitals shared all drugs increased from US$675.3 in 2015 to even though it is an essential part of with community health stations,which USS 844.2 in 2016.The deficit arose the Luohu model.Nevertheless,we are reduced unnecessary outpatient visits because the global budget was based on planning to use patient-reported experi- to hospitals.Finally,health promotion medical costs in previous years,rather ences as a measure for integrated care to staff in primary health-care teams have than the costs of all aspects of integrated evaluate the Luohu model.Evaluation sought to improve health literacy in the care.Cost of preventive and other public results,in turn,will influence the imple- population since establishment of the health care,such as cancer screening mentation of the remaining strategies or hospital group.The proportion of the programmes for residents older than care integration. population with basic health literacy in 50 years and pneumonia vaccination for Although the health ministry rolled Luohu increased from 9.3%(136710 of residents older than 60 years old,were out the Luohu model to other urban ar- 1.47 million)to21.3%(315240of1.48 not included.The finance ministry of eas of China,it will take time before the million)in the first two years of the pro- Shenzhen city made up for the budget model is implemented nationwide.From gramme.3 This compares with a national deficit of the hospital group by reorga- September to December 2017,more figure of 11.6%in a survey of 84987 nizing health expenditure for public than 1500 policymakers from health and people in 2016.Health literacy enables health providers.Before establishment other social sectors in 321 cities received people to increase control over their of the hospital group,public health care on-site training in Luohu.The concept health and health determinants,while was mainly provided by three kinds of and mechanism of the Luohu model health promotion activities promote facilities:specialized public health-care were adopted by most cities in China. mutual trust between the population facilities (including disease prevention However,some strategies could not be and staff of community health stations and control facilities,and health super- implemented in some cities,due to lack We therefore believe that improving the vision facilities);primary health care of resources and lack of support from population's health literacy contributed facilities (community health stations); the of finance ministry and the social to changing attitudes and behaviour and hospitals.The ministry recalcu- security ministry.For example,insuf- about using community health stations lated the budget of public health care in ficient numbers of general practitioners in Luohu. 2017 for the hospital group based on the may delay the development of primary These four strategies could be ap- care provided in 2016. health-care teams,while the health min- plied directly to health-care systems We suggest that finance ministries istry cannot promote health insurance in other urban areas of China.An in- in other cities or regions rolling out such payment reform without coordination creased supply of general practitioners a model of care,need to consider public with the social security ministry.Some Bull World Health Organ 2018;96:843-852 doi:http://dx.doi.org/10.2471/BLT.18.214908 849Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 849 Policy & practice Xin Wang et al. People-centred care in urban China and collaboration across tiers. Trust needs to be built for collaboration be￾tween institutions in other health-care systems. Changing patient behaviour The second challenge was how to change the behaviour of the population towards using community health stations as the first point of contact, rather than going to hospitals. In the Luohu model, four strategies were used to overcome this cultural challenge. The first strategy was capacity-building in community health stations. Technical assistance from district-level hospitals contributed to the improvement of care quality in commu￾nity health stations. The second strategy was people-centred care in community health stations. For example, in response to the needs of elderly patients confined to bed, the community health stations provided home visits to avoid unneces￾sary hospital admissions and maintain patients at home, while reducing the burden of care on family members. The third strategy was ensuring ad￾equate supplies of common drugs in community health stations. According to a study of 22 city-level hospitals in Beijing, one-third of patients attended hospitals solely to receive drugs (num￾bers not stated).28,29 In the Luohu model, district-level hospitals shared all drugs with community health stations, which reduced unnecessary outpatient visits to hospitals. Finally, health promotion staff in primary health-care teams have sought to improve health literacy in the population since establishment of the hospital group. The proportion of the population with basic health literacy in Luohu increased from 9.3% (136 710 of 1.47 million) to 21.3% (315 240 of 1.48 million) in the first two years of the pro￾gramme.30 This compares with a national figure of 11.6% in a survey of 84 987 people in 2016.31 Health literacy enables people to increase control over their health and health determinants, while health promotion activities promote mutual trust between the population and staff of community health stations. We therefore believe that improving the population’s health literacy contributed to changing attitudes and behaviour about using community health stations in Luohu. These four strategies could be ap￾plied directly to health-care systems in other urban areas of China. An in￾creased supply of general practitioners in Luohu was also important for provid￾ing the capacity to support integrated care through the gatekeeper strategy. During the period 2015–2017, the num￾ber of general practitioners in the group increased from 89 to 194, based on offer￾ing higher salaries and training in task￾shifting for some specialists. In 2017, there were 3.02 general practitioners per 10 000 residents in Luohu, compared with an average of 1.38 per 10 000 for the entire country.22 Policymakers in other health-care systems might con￾sider general practitioner training of some specialists and task-shifting from general practitioners to experienced nurses and public health physicians to fill the general practitioner gaps in the short term. Reducing costs The third challenge was how to avoid budget deficits in the first year. The goal of lower financial burdens has not been achieved in the first two years of the Luohu model. The 2016 global budget of the Luohu model was given by the total cost of health insurance for registered residents in the previous year, multiplied by the average growth rate of the health insurance fund in 2016. However, the average cost of integrated care per registered resident in the group increased from US$ 675.3 in 2015 to US$ 844.2 in 2016. The deficit arose because the global budget was based on medical costs in previous years, rather than the costs of all aspects of integrated care. Cost of preventive and other public health care, such as cancer screening programmes for residents older than 50 years and pneumonia vaccination for residents older than 60 years old, were not included. The finance ministry of Shenzhen city made up for the budget deficit of the hospital group by reorga￾nizing health expenditure for public health providers.32 Before establishment of the hospital group, public health care was mainly provided by three kinds of facilities: specialized public health-care facilities (including disease prevention and control facilities, and health super￾vision facilities); primary health care facilities (community health stations); and hospitals.33,34 The ministry recalcu￾lated the budget of public health care in 2017 for the hospital group based on the care provided in 2016. We suggest that finance ministries in other cities or regions rolling out such a model of care, need to consider public health-care expenditure when calculat￾ing global budgets for hospital groups, to avoid budget deficits in the first year. Next steps There are two remaining steps in the application of the Luohu model. First, several strategies have not yet been implemented (Table 1), including risk stratification, individual care plans for patients, integrated clinical pathways for care integration, decision support and certification. The Luohu hospital group is preparing to implement a risk stratification exercise based on disease burden.22 Once high-risk patients have been identified, individual care plans will be made. Clinical pathways are be￾ing created to standardize the treatment and referral pathways between provid￾ers and to integrate care and support decision-making. Second, monitoring and evaluation is necessary to determine the effectiveness of the Luohu model over time. Despite the new self-evalua￾tion system, more indicators related to people-centred care, population health and financial burden over the long-term are required. Although residents’ satis￾faction with health care in Luohu district was high, their experience of integrated care was not a focus of the present study, even though it is an essential part of the Luohu model. Nevertheless, we are planning to use patient-reported experi￾ences as a measure for integrated care to evaluate the Luohu model. Evaluation results, in turn, will influence the imple￾mentation of the remaining strategies or care integration. Although the health ministry rolled out the Luohu model to other urban ar￾eas of China, it will take time before the model is implemented nationwide. From September to December 2017, more than 1500 policymakers from health and other social sectors in 321 cities received on-site training in Luohu. The concept and mechanism of the Luohu model were adopted by most cities in China. However, some strategies could not be implemented in some cities, due to lack of resources and lack of support from the of finance ministry and the social security ministry. For example, insuf￾ficient numbers of general practitioners may delay the development of primary health-care teams, while the health min￾istry cannot promote health insurance payment reform without coordination with the social security ministry. Some