iDSI has been collaborating with China (through NICE International’s earlier engagements with CNHDRC) since 2012. See below for further information on events and work that took place between November 2012 and September 2015.
NICE signs MOU with CNHDRC during UK-China health talks
NICE International developed and delivered a two-week study tour programme for a senior delegation from China. We worked in collaboration with the British Embassy in Beijing and the UK Department of Health.
The study tour was organised as part of the People to People Dialogue (P2P), one of the UK’s key ministerial-level talks with China.
The delegation comprised 25 high level officials. The officials included seven division heads from the National Health and family Planning Commission (NHFPC) and the Director General of the CNHDRC (NICE International’s collaborator on the Clinical Pathways project.)
Week 1 – Introduction to NICE and the NHS
The study tour began on the 9th September 2015, with representatives of the delegation receiving an introduction to the NHS and the work of NICE. Speakers included representatives from the Kings Fund (John Appleby and Chris Ham) and NICE (Kalipso Chalkidou, Francis Ruiz and Sir Andrew Dillon).
The delegation visited the Royal London Hospital where Professors Tony Rudd and Mike Roberts gave presentations on UK stroke services and COPD management (areas covered by the ongoing Clinical Pathways project). The presentations emphasised the need for better integration and innovation at different levels of the health system. Professors Rudd and Roberts also stressed the importance of evidence informed guidance to support practice change and guide monitoring and performance improvement.
Later during the first week the delegation visited the King’s Health Partners. The visit helped to reinforce issues related to better coordination between healthcare providers and academia and the importance of supporting research excellence directly aligned with improving patient care.
It was noted that institutions such as NICE have a key role in supporting the translation of research evidence into policy recommendations that can feed into actual practice change.
The end of the first week culminated with a visit to the Department of Health. The delegation was given an overview of the UK NHS, the approach to branded pharmaceutical pricing and the work being undertaken on Global Health Security. There was a focus on the enormous challenge presented by antimicrobial resistance (AMR).
Week 2 – visits, MOU and panel discussion
The second week of the study tour involved:
- a visit to the Health and Social Care Information Centre in Leeds,
- a presentation from Professor Andrew Stevens on the experience of being a Chair of a NICE Technology Appraisals committee
- a session on the role of the NIHR Horizon Scanning Centre, based at the University of Birmingham.
- and a talk from of the Association of the British Pharmaceutical Industry.
UK – China health dialogue
A key highlight of the second week was the UK-China Health Dialogue that took place in the historic environment of the Royal College of Surgeons in Lincoln’s Inn Fields, London.
Keynote speeches were delivered by:
- Liu Yandong, Vice Premier of China,
- the Rt. Hon Jeremy Hunt MP,
- Margaret Chan, Director-General of the World Health Organisation.
All the speakers noted the mutual and international benefits following from greater UK-China cooperation in health.
Vice Premier Liu Yandong noted that other countries including China wished to learn from the “British model” of healthcare funding and provision, whilst highlighting the importance of finding “Chinese solutions” to health system reform.
Margaret Chan highlighted the issue of AMR, noting that the UK and China could work together to identify a multi sectoral approach to this challenge, which also has policy coherence.
Jeremy Hunt made reference to examples of important UK-China partnerships in health including the relationship between NICE International and CNHDRC. He noted that NICE and the CNHDRC had agreed a new Memorandum of Understanding (MOU) during this P2P for further cooperation in areas of evidence informed policy making.
Memorandum of understanding
The MOU between NICE and CNHDRC builds on the successful collaboration between NICE International and CNHDRC in the area of clinical pathways.
Spanning five years, the MOU details the process, methods and research needed to develop clinical guidelines and quality standards in China.
Under the MOU, NICE International will provide technical help on the development of frameworks that will lead to locally relevant and locally owned clinical guidelines and quality standards.
The collaborative project will pilot work in conditions selected as high priority, which have a high disease and economic burden. AMR, drawing on NICE’s recent (2015) stewardship guidelines, will be considered for the pilot.
The MOU was signed by Li Tao, Director General of CNHDRC and Sir Andrew Dillon, CEO of NICE.
The Health Dialogue culminated in a panel session moderated by the UK’s Chief Medical Officer, Professor Dame Sally Davies.
The panellists were:
- Director General Li Tao (CNHDRC),
- Director General Zhang Zongjiu of the Bureau of Medical Administration (NHFPC),
- Kalipso Chalkidou of NICE International
- Lord Jim O’Neill, Commercial Secretary to the UK Treasury and chair of a review into AMR.
Both DG Li Tao and DG Zhang Zongjiu highlighted their key observations from the study tour. They referenced the role of NICE in the UK and their ambition to work with NICE through its international unit to establish a similar priority setting institution in China.
DG Li Tao wished to deepen the existing collaboration with NICE International, through iDSI to develop health technology assessment in China.
NICE International holds final discussions with CNHDRC ahead of Clinical Pathways dissemination event in October
Francis Ruiz and Laura Morris travelled to Beijing in July 2015 as part of the continuing collaboration with the China National Health and Development Research Centre (CNHDRC). The CNHDRC is a think tank of the National Health and Family Planning Commission, the former Ministry of Health.
The aim of the July visit was to meet with researchers at CNHDRC to discuss the analytical work to date on the Clinical Pathways project (Phase 2), with its focus on managing COPD and stroke. Participants at the meeting also discussed preparations for a major meeting planned for October 2015. This meeting will involve key stakeholders and participants in the pathways project, including administrators and clinicians from the implementing hospitals at four sites in rural China.
The October event will include the launch of a book (in both Chinese and English) describing the clinical pathways project, the NICE International-CNHDRC collaboration and the methods for devising the clinical pathways, which involved both Chinese and international experts who partnered with NICE International on the project.
The book will also present the quantitative and qualitative findings from an analysis of the impact of introducing the pathways with payment reform in the participating study hospitals. This analysis was the focus of the project meetings in July, where participants discussed the statistical approaches used to look at before-and-after comparisons of key indicators and the identification of appropriate quality measures.
NICE International visit China with Indian colleagues
As part of an on-going collaboration with the Center for Health Policy and Technology Assessment, a division of the China National Health Development Research Center (CNHDRC), NICE International representatives travelled to China to discuss latest developments on the “Clinical Pathways Phase 2” project. In addition, two colleagues from India joined the discussions and also participated in a visit to a project study site in Qianjiang. Dr Nagesh Prabhu (Joint secretary, Department of Health Research, Minister of State for Health & Family Welfare) and Dr. Raju Sukumaran (Medical officer, Comprehensive Health Insurance Agency, Kerala) were provided an overview of the collaboration between NICE International and CNHDRC, that included a description of the work done during Phase 1 with its focus on developing evidence informed surgical pathways linked with payment reform.
The clinical pathways developed as part of Phases 1 and 2 are one component of a multi-faceted and complex intervention that has included capacity building, multi-stakeholder engagement, and changes in IT infrastructure and performance management strategy within the study hospitals. Notably, Phase 2, with its emphasis on pathways for non-communicable disease (stroke and COPD) has also facilitated efforts for improving integrated care across multiple tiers in the rural health system. This is strongly exemplified by Qiangjiang hospital, which under the leadership of Mr Liu, has worked to develop effective referral pathways and closer links with township health centres as part of Phase 2 pathway implementation. This strengthening of links across multiple tiers has also benefited from the use of technologies such as telemedicine which allows Qianjiang hospital experts to provide diagnostic and care support to township health centres thereby reducing the need for patients to travel.
Drs Prabhu and Sukumaran noted that a key feature of the pathways project has been the apparent success associated with its implementation, including the importance of stakeholder buy-in and local leadership to support behaviour change. CNHDRC has worked intensively with each study site in developing the pathways and getting them integrated within hospital IT systems.
CNHDRC representatives plan to further share their findings during a dissemination visit to India later in 2015. This will also provide an opportunity both Indian and Chinese colleagues to share their experiences and support the further institutionalisation of evidence-informed decision making.
NICE International visit China to provide support to colleagues in pilot counties
Between 23 and 28 November 2014, NICE International visited China, to provide support to our counterparts, the China National Development and Research Centre and our county level colleagues in select pilot counties, to adapt and implement Clinical Pathways for high burden chronic diseases, such as stroke and COPD.
The trip was funded by the FCO’s Prosperity Fund and DFID UK, and the team included Professor Martin McShane, head of long term conditions for NHS England and a GP, Professor John Appleby, Chief Economist of the King’s Fund and Dr Kalipso Chalkidou, Director of NICE International.
The visit highlighted the challenges the Chinese and English systems share, including managing performance, measuring quality and ensuring payment incentives are aligned with the system’s objectives; care integration and care coordination across tiers and settings and gaining professional and patient buy-in during the reforms.
The team visited two rural counties in Eastern China and one city:
Donghai county, Jiangsu province
Donghai county is initiating an integrated care pilot supported by the FCO, aiming at streamlining referrals between county hospitals, township clinics and village clinics.
We met with heath authorities and hospital management of the local county and township hospitals as well as a village clinic and were introduced to the telemedicine infrastructure which allows professionals at different tiers to interact with one another – facilitating referrals and coordinated care.
Jiaonan county, Shandong province
Jiaonan county has been working with NICE and CNHDRC under the DFID project of clinical pathways for NCDs since 2013, with an emphasis on stroke and COPD, major drivers of disease burden in the county.
In Jiaonan, we visited the new county hospital (600 beds) including a dedicated stroke ward. We heard about the progress of the pilot, including the collection of patient reported outcome measures using EQ-5D, and the implementation of payment reform to encourage participation of patients to the Clinical Pathway.
The Clinical Pathway, in addition to introducing standardised management of NCDs, emphasises the importance of secondary prevention (e.g. continuous management of risk factors at village and township level post-discharge) and also rehabilitation and patient education, and seeks to align payment to ensure the above are implemented.
Qingdao city, Shandong province
A city of 8 million peopple in a special growth zone, which launched, during our visit, a clinical pathways pilot on stroke with a view to emulating, in parallel to the pilot, the reconfiguration of stroke services in London.
We have been working with Qingdao for over a year, with support from Professor Tony Rudd, national director for stroke for NHS England, and signed an MoU earlier this year to support the City with its healthcare reforms. Qingdao’s pilot involves both the health and social security authorities, representatives of both being present at the launch, and it’s Chinese component is funded by the municipality.
Qingdao Health Bureau and NICE sign a Memorandum of Understanding
The Head of the Qingdao Health Bureau, Mr Cao Yong and the Deputy Chief Executive of NICE, Dr Gill Leng, signed a Memorandum of Understanding between the two organisations. The aim of the MoU is to enhance collaboration and two way learning with a particular focus on NICE’s Approach to technology assessment and quality improvement in the field of non-communicable diseases. The ceremony was held at the Foreign and Commonwealth Offices in London and witnessed by the Chinese Vice Minister of health Mr Chen and the British Public Health Minister Jane Ellison. Qingdao is a major city in eastern China, with a population of over 8 million and one of the fastest rates of economic growth across Chinese cities and this is the first MoU between NICE and the health authorities of a major city overseas.
We look forward to working with the Qingdao authorities, with support from our partners in China, the China National Health and Development Research Centre, to promote quality and efficiency in health and we hope this partnership will serve as a model for other Chinese cities.
NICE and CNHDRC facilitated an introduction between the Qingdao health authorities and NHS London which also signed a bilateral agreement. This follows on from a NICE mission to Qingdao, in the spring of 2013, during which Professor Tony Rudd discussed with Qingdao officials the success of the London reconfiguration of stroke services, a project the Chinese colleagues felt would be relevant and useful to their own setting.
Following the signing, the Ministerial and Qingdao delegations visited NICE as well as other NHS organisations, including the Riverside Medical Centre at Vauxhall, the Waldron GP Walk in Centre in Lewisham, the Hurley Clinic in Kennington and St. Thomas’s Hospital.
Pilot project in China
The China National Health Development and Research Centre (CNHDRC) in collaboration with NICE International have embarked on a pilot project involving the design and implementation of evidence informed pathways of care, linked with payment reform with an emphasis on integrated care, for two high priority disease areas (chronic obstructive pulmonary disease [COPD] and stroke). This builds on the initial (Phase I) ‘Clinical Pathways’ (CP) project associated with the Health XI initiative and initiated in 2009, with WB, DFID China an DFID UK support.
The development of these pathways for this high burden diseases involves iterative input from experts in China and the UK, and are based on existing management strategies in the pilot counties. As part of this iterative exchange, in June 2013, a visit was made by NICE International experts and a Chinese-led team (including the Director of Qianjiang Central hospital of Chongqing city which was involved in the Phase I project) to two of the four counties selected for participation in Phase II (Wen county and Jiaonan county). The visit included dedicated sessions with relevant hospital staff to provide feedback on current practice and the draft clinical pathways on stroke and COPD.
The choice of stroke and COPD as topics for pathway development requires a consideration of how multiple tiers within the existing health system interact and cooperate. Consequently the visit to the provinces additionally included exposure to township hospitals and village health centres to understand existing facilities, patterns of working, and opportunities for vertical cooperation. In addition, the clinical pathways will be developed in such a way as to facilitate their full incorporation within existing provider IT systems. This visit therefore also included a brief assessment of IT facilities specifically in relation to supporting the objectives of CP implementation.
The NICE International and the Chinese-CNHRC delegation met with senior hospital and health centre staff, and also officials from the local health bureau. There was acknowledgement from the pilot sites and local policy makers of the importance of evidence-based practice and the development of quality indicators alongside payment reform.
- Peninsula Metropolis Daily, Huangdao District People’s Hospital, innovation of reform of public hospitals – ‘The roc spreads wings and soars; a blessing for common folk’ (google translation)
- Press release by Jiaonan hospital, CNHDRC clinical pathways project has made significantly progress in our hospital (google translation)
The Chairman of NICE and the Director of NICE International spent a few days in Beijing meeting with NICE’s major partners in China and publicising NICE’s work in the rural health reforms.
The meetings included a day-long meeting at Renmin University, the fifth annual bilateral conference between NICE and Renmin, which, this year, was focused on care quality, hospital reform and the role of integrated care, including primary care. The conference, hosted by Renmin, one of the most prestigious and oldest universities in China, with a track record in social sciences and health policy in particular, was attended by over 100 colleagues from across China, including the Beijing and Shanghai Health Bureaus, the newly formed National Health and Family Planning Commission (NHFPC), the Ministry of Human Resources and Social Security, as well as officials from the provinces, academics and hospital administrators. We look forward to continuing and intensifying our partnership with Renmin in the coming year.
On the second day of our visit we met with senior officials from the World Bank and with our long-term partners in China, the think tank of the ministry of health, the China National Health and Development Research Centre (CNHDRC). We discussed progress with implementation of our NCD clinical pathways across four rural pilot counties and plans for scaling the pilots up.
On day three we had the honour of meeting, together with CNHDRC, the Director General of Planning and Information, a new division at the NHFPC, with her colleagues, including the officer leading on the design of the 13th 5-year strategic Plan and the Head of international affairs for Europe and North America. All three sides reiterated their commitment to working together, emphasising the need to improve efficient resource allocation at the micro/technology and macro/service delivery levels, and the importance of good quality community/primary care as the only means of achieving sustainable universal coverage.
This meeting was followed by a high level session with Vice Minister Ma where the Vice Minister called for NICE to continue and intensify its involvement in the Chinese health reforms, incl. urban health reforms, public hospital reforms incl. referral pathways and integration between prevention and treatment, and low and high tier hospitals. The Minister called for a strategic partnership between NICE, the Ministry and CNHDRC for institutionalising a Chinese model of Health Technology Assessment to meet China’s needs.
The second half of the day was spent at the Development Research Commission, the prestigious think-tank of the State Council, the Chinese equivalent of the Cabinet Office. The session was attended by colleagues from the National Development and Reform Commission, the NHFPC and different DRC divisions, and was supported by the British Embassy in Beijing. NICE offered to work with DRC in their research on HTA and quality standards and how these notions relate to the ongoing Chinese health reforms.
China EQ-5D workshop
The EuroQol Group, in partnership with NICE International, delivered a one-day workshop on the EQ-5D to researchers and officials from the China National Health Development Research Center (CNHDRC) and academics from Beijing and Nanjing, among others.
The EuroQol speakers were: Professor Nancy J. Devlin, Director of Research, Office of Health Economics, London and Chair of the EuroQol Group Executive Committee; and Professor Jan van Busschbach; Director of the Department for Medical Psychology and Psychotherapy, Erasmus University and Chair of the EuroQol Group Board. The workshop was co-chaired by Francis Ruiz of NICE International and Professor Zhao Kun from the CNHDRC, Division of Health Policy Evaluation and Health Technology Assessment.
The topics covered included: origins of the EQ-5D, the recent development of the five-level version, and the use of EQ-5D in decision making and in health service performance management (the UK PROMs programme). One important area of discussion among all participants related to the availability of appropriate Chinese value-sets for the EQ-5D (three-level and five-level) and potential further research opportunities.
Clinical pathways and payment reform project launched in China
November 6-7, 2012
China National Health Development Research Center (CNHDRC) and NICE International launched their collaboration project on implementing evidence informed clinical pathways in China.
The two-day event was titled “Strengthening evidence-based policy making to achieve universal healthcare: Clinical pathways and payment reform in China and its dissemination”, and included participation from local and national policy makers (Ministry of Health, Ministry of Commerce, Ministry of Finance, the National Development and Reform Commission, among others), representatives from rural county hospitals implementing the pathways, and foreign experts from the UK, India, Nepal and the Netherlands. Also in attendance were members of the British Department for International Development (DFID) China. The conference was supported by the Chinese Ministry of Health and DFID.
Attendees heard details of the clinical pathways project and discussed evidence-based management of patients with Chronic obstructive pulmonary disease (COPD) and stroke, the chosen areas for Chinese pathway development. In addition, there were presentations from representatives from India (the Head of Audit for the Aarogyasri Scheme of the State of Andra Pradesh, and a representative of the Department of Health Services and the National Rural Health Mission in Kerala) and also from Nepal (a senior clinician and researcher and his Excellency, the Ambassador of Nepal in Beijing). Attendees at the conference also heard from a representative of PharmAccess, a Dutch NGO with a significant track record in Africa.
The two-day conference was followed by a meeting at CNHDRC offices to discuss potential mutual learning projects between China and other countries, in the framework of ‘South-South’ collaboration.
In March 2013, Health Affairs published a report on the clinical pathways pilots in rural China aiming at improving quality and efficiency in a series of high burden chronic diseases, with support from NICE