11 Chinese Government Departments Issue Guidelines to Promote Nursing Industry Development with Emphasis on IT-Enabled and Community-Based Care

VCBeat (WeChat ID: vcbeat) has learned that today, the National Health Commission, the National Development and Reform Commission, and nine other departments jointly issued the “Guiding Opinions on Promoting the Reform and Development of the Nursing Service Industry” (hereinafter referred to as the “Guiding Opinions”).

The guidelines indicate that the goal for the reform and development of China’s nursing industry is to have more than 4.45 million registered nurses by 2020, while further refining requirements for the nursing system and regulations. VCBeat has conducted a further analysis in light of the latest policies.

Nursing care plays a significant role in advancing the Healthy China initiative, promoting the development of the health service industry, and enhancing the health and well-being of the population. In 2017, the total number of registered nurses in China exceeded 3.8 million, with 2.74 nurses per 1,000 population and a doctor-to-nurse ratio of 1:1.11.

By 2020, the total number of registered nurses will reach 4.45 million. In his report to the 19th National Congress of the Communist Party of China, General Secretary Xi Jinping pointed out that the Healthy China Strategy should be implemented to provide comprehensive, life-cycle health services to the people. Efforts should be made to promote the integration of medical care and elderly care, and to accelerate the development of both undertakings and industries related to aging. Nursing services cover the entire human life span—from birth through aging, illness, and death—playing a vital role at every stage, including the acute phase, chronic phase, and end-of-life care.

Accelerating the reform and development of the nursing service industry and increasing the supply of nursing services will help precisely meet the diverse and differentiated health needs of the people in the new era. To fully implement the spirit of the 19th National Congress of the Communist Party of China and the National Conference on Health and Wellness, further promote the reform and development of the nursing service industry, and support the construction of a Healthy China, our Commission, in conjunction with relevant departments including the National Development and Reform Commission, the Ministry of Education, the Ministry of Civil Affairs, and the Ministry of Finance, has drafted the "Guiding Opinions on Promoting the Reform and Development of the Nursing Service Industry."

The guidelines indicate that the nursing workforce will achieve the following targets by 2020:

1. The nursing service system is sound and well-developed. A nursing service system supported by institutions, based in communities, and centered on home care has been basically established, forming a comprehensive framework that covers acute-phase diagnosis and treatment, chronic-phase rehabilitation, stable-phase care, and end-of-life palliative care. The nursing service industry has grown rapidly, with a significant expansion in the scale of the nursing sector.

2. The nursing workforce has achieved substantial development. The size, quality, and competencies of the nursing workforce are basically able to meet the needs of health sector development and the public’s health demands. The total number of registered nurses exceeds 4.45 million, with more than 3.14 registered nurses per 1,000 population. The ratio of physicians to nurses is no lower than 1:1.25, and the total number of nurses in primary healthcare institutions exceeds 1 million. A nursing workforce comprising registered nurses and auxiliary nursing personnel has been established, with a significant increase in the number of caregivers specializing in elderly care and maternal and infant care.

3. Nursing service supply is more rational. Nursing services in medical institutions are orderly and reasonable, with closer division of labor and collaboration. The number of post-acute care institutions, such as nursing homes, nursing centers, rehabilitation medical centers, and hospice care facilities, has increased significantly. The supply of services including rehabilitation nursing, geriatric nursing, disability nursing, maternal and infant nursing, and hospice care continues to expand. Community-based and home nursing services have further developed.

4. Nursing service capabilities have been significantly enhanced. High-quality nursing services now achieve full coverage, the development of nursing disciplines has been strengthened, and the level of specialized nursing continues to improve. Service capabilities in rehabilitation nursing, traditional Chinese medicine (TCM) nursing, geriatric nursing, maternal and infant care, home-based nursing, and palliative care have been effectively improved, leading to a marked increase in public satisfaction.

The “Guidance Opinion” is divided into seven parts:

Part I: General Requirements. This section clarifies the overall approach, basic principles, and main objectives for promoting the reform and development of the nursing service industry.

Part II: Establish a High-Quality and Efficient Nursing Service System. Improve the medical nursing service system and strengthen the health and elderly care service network.

Part III: Strengthening the Training and Workforce Development of Nursing Professionals. We should actively promote the training of nursing students in academic institutions, provide on-the-job training for clinical nurses, strengthen the nursing workforce, accelerate the training of auxiliary nursing personnel, and enhance the standardized management of nursing assistants.

Part IV: Innovative Nursing Service Models. Continuously promote high-quality nursing services, gradually advance transitional care services, and vigorously develop community- and home-based nursing services.

Part V: Strengthening the Nursing Discipline and Enhancing Traditional Chinese Medicine (TCM) Nursing Capabilities. Strengthen nursing quality and safety management, and improve the service level of TCM nursing.

Part VI: Policy Measures. Reasonably adjust the pricing of nursing services to fully mobilize the enthusiasm of nurses, improve training and employment policies for nursing assistants, strengthen the development of nursing information systems, encourage the growth of commercial long-term care insurance, and vigorously promote the development of the nursing industry.

Part VII: Organization and Implementation. Strengthen organizational leadership, enhance division of labor and collaboration, encourage innovative pilot programs, and intensify public opinion campaigns.

Previously, the last major policy document on nursing was the Outline of China’s Nursing Career Development Plan (2011–2015). Compared with its key provisions, in addition to continuing to deepen nursing system reforms in public hospitals and strengthening training for nursing professionals—routine measures—VCBeat believes the following key points deserve attention:

1. Further segmentation of the medical care service system, with accurate positioning of medical institutions at all levels

The Guidelines state that, in accordance with the requirements of the tiered diagnosis and treatment system and the development of medical consortia, functional positioning should be implemented for medical institutions at all levels and types, and a scientifically sound division of labor and collaborative mechanism should be established among hospitals at different levels, as well as between hospitals and primary care institutions and post-acute care institutions.

By encouraging and promoting the establishment of nursing institutions by non-governmental entities, as well as facilitating the transformation of certain primary and secondary hospitals, we aim to stimulate market vitality and expand the supply of services such as elderly care, disability care, rehabilitation care, maternal and infant care, and palliative care.

Tertiary hospitals primarily provide nursing care for patients with complex, critical, and life-threatening conditions, while strengthening the development of the nursing discipline and talent cultivation. Secondary hospitals mainly provide nursing care for common and frequently occurring diseases. Nursing homes, nursing centers, rehabilitation medical centers, hospice care institutions, and primary healthcare facilities primarily offer services such as daily medical nursing, geriatric care, disability care, rehabilitation nursing, long-term care, and hospice care.

Similar to tiered diagnosis and treatment, nursing services provided by hospitals at various levels are stratified to meet the needs of different populations, essentially constituting a “tiered diagnosis and treatment” model within the field of nursing.

2. Leveraging Information Technology to Innovate Nursing Service Models

With the surge in popularity of “Internet Plus” healthcare services, “shared nurses” have become a hot topic within the industry. In essence, nursing services branded as “shared” are actually “Internet Plus Nursing” services delivered via online platforms, commonly known as “home-visit nursing.” Unlike physician home visits—which benefit from policy support for physicians’ multi-site practice and family doctor programs—nurses’ multi-site practice has only been gradually permitted in a few regions, such as Guangdong and Beijing. Furthermore, the risks associated with home-visit nursing and its high costs introduce greater uncertainty to this innovative service model.

Furthermore, in the realm of information technology, emphasis is placed on strengthening the informatization of nursing. By leveraging the rapid development of information technologies such as big data, cloud computing, the Internet of Things (IoT), and mobile communications, we will vigorously advance nursing informatization, actively optimize nursing processes, innovate nursing service models, and enhance nursing efficiency and management effectiveness. We will promote innovation in lifestyle-oriented service formats within the nursing sector, improve service workflows, and actively foster new business models such as smart health nursing.

Meanwhile, the guidelines also emphasize “smart nursing” in hospitals. They point out that the coverage of high-quality nursing services should first be expanded to achieve full coverage in all secondary and tertiary hospitals. Hospitals are required to leverage information technology to provide patients with whole-process, seamless, professional, and convenient smart nursing care.

This also means that not only will the clinical consultation process be digitalized, but nursing services will also adopt standardized procedures, further promoting high-quality nursing care in public hospitals and potentially significantly reducing incidents such as administration of incorrect injections or medications.

3. Encourage the development of commercial long-term care insurance

In July 2016, China’s Ministry of Human Resources and Social Security issued the “Guiding Opinions on Launching Pilot Programs for the Long-Term Care Insurance System,” deciding to initiate pilot programs in 15 regions, including Chengde City in Hebei Province, Changchun City in Jilin Province, Shanghai, and Chongqing. In January 2017, Shanghai took the lead in piloting long-term care insurance in three districts—Xuhui, Putuo, and Jinshan—and began expanding the pilot program citywide in January 2018. The promotion of long-term care insurance has ushered in significant development opportunities for a number of elderly care nursing companies.

The guidance further points out that localities with the necessary conditions are encouraged to actively support commercial insurance institutions in developing long-term care commercial insurance, as well as commercial health insurance products related to elderly care services. Efforts should be made to vigorously develop diversified, multi-tiered, and standardized commercial nursing insurance services, and to explore mechanisms for cooperation between commercial insurance companies and institutions providing elderly care services.

Although long-term care insurance is being gradually implemented, its assessment mechanisms and benefit payment limits are still undergoing continuous improvement.

Given that basic medical security has led to a deficit in health insurance funds, the demand for healthcare coverage increasingly calls for tiered solutions tailored to individuals with varying spending capacities and socioeconomic statuses. The collaboration between elderly care institutions and commercial insurers inevitably sparks consideration of the feasibility of this new exploratory pathway.

Compared with diagnostic and treatment services, nursing care involves a longer service cycle. As commercial insurance has become a new avenue for ordinary families to mitigate disease risks, whether nursing services can leverage commercial insurance remains open to discussion.

4. Develop the nursing assistant system and accelerate the training of auxiliary nursing personnel

Faced with a care demand of 40 million, there is a significant gap in meeting the caregiving tasks required by the social environment. From the supply side, the annual output of professional nursing talent is far from sufficient. Nursing schools, which form the base of the nursing talent pyramid, only produce hundreds of thousands of graduates each year. The majority of care workers are drawn from the cohort born in the 1940s and 1950s. These individuals are often labeled as “from rural areas,” “with low educational attainment,” “poorly compensated,” and “highly mobile.” Consequently, professional standards for care workers have been introduced.

The Guidelines propose three key measures: “accelerating the training and development of auxiliary nursing staff,” “strengthening the standardized management of nursing assistants,” and “improving policies for the training and employment of nursing assistants.” These measures involve establishing management systems for nursing assistants and safeguarding their lawful rights and benefits. Particular emphasis is placed on qualified labor dispatch agencies and domestic service providers to establish and improve management and dispatch systems for nursing assistants, conduct regular training, and ensure service quality. Further regulations are introduced to address current irregularities in the patient care attendant market, thereby reducing the risks associated with hiring unregulated individuals to provide nursing care for patients.

Meanwhile, to address the shortage of nursing staff, efforts are encouraged to convert surplus labor, such as rural workers, into workforce for the nursing care service industry. Priority support is given to training programs for transferred rural laborers and registered unemployed urban residents to become certified nursing assistants. Fully leverage policies and funds that promote employment and entrepreneurship, encouraging individuals from all backgrounds to seek employment or start businesses in the nursing care service sector. Eligible practitioners shall receive relevant subsidies in accordance with established regulations.

Zhang Junhua, Deputy Director of the Talent Center of the National Health Commission, pointed out that proposals regarding nursing assistants at this year’s Two Sessions included the following three points: 1. The nursing assistant system must not be abolished, and certification must be mandatory for practice; 2. Establish diversified channels for the training and deployment of nursing assistants; 3. Develop a reasonable incentive mechanism for compensation and benefits. As the demand for nursing professionals shows a trend toward diversification, the training of nursing assistants is also moving in a diversified direction.

5. Encourage mentorship and guidance to enhance nursing capabilities in primary healthcare institutions

The guidelines emphasize encouraging hospitals at the secondary level or above within medical consortiums to support and drive improvements in nursing service capabilities at primary healthcare institutions through measures such as establishing joint nursing teams, providing one-on-one mentoring, and conducting training for community nurses.

and encourage qualified post-acute care institutions and primary healthcare facilities to provide day care, home nursing, and home hospital beds. By establishing medical consortia, promote the downward flow of high-quality nursing resources from large hospitals, thereby supporting and driving the enhancement of nursing service capabilities in post-acute care institutions and at the primary level.

Primary healthcare institutions serve as the largest entry point for patient flow. However, due to limited diagnostic and treatment capabilities, they can only provide basic services such as routine pharmaceutical care for common and chronic diseases, health management, and nursing care.

In China, nursing professionals are primarily employed in medical institutions to provide healthcare services, while a portion of them deliver community-based nursing care at the grassroots level. Only a small fraction of nursing talent works in elderly care institutions or long-term care facilities. At this level, the distribution of nursing personnel largely follows the "siphon effect," whereby major hospitals attract the majority of skilled professionals.

Zhang Guangpeng, Director of the Health Workforce Research Office at the Health Development Research Center of the National Health Commission, once stated, “There is a 30% waste in the placement and utilization of senior nurses.” Therefore, in the face of a health service system with enormous demand, as well as nursing systems for rehabilitation, elderly care, and chronic disease management, nurses “should play a greater role and are capable of doing so.”

There is a significant gap between the current community health service institution-led primary care nursing model and the public’s growing demand for nursing services. Therefore, within the context of Anhui Province’s healthcare reform initiatives overseen by the State Council’s Healthcare Reform Office, the practice of senior nurses in primary care settings has emerged as a typical example of innovative models for cultivating nursing talent.

In the practice of senior nurses in Anhui Province, after undergoing training and credentialing, their primary roles at community health centers encompass three key aspects:

First, within the medical consortium, senior nurses serve as personnel liaisons to strengthen inter-institutional connections;

Second, provide guidance on nursing services, with a particular focus on infection control and nursing management in primary healthcare institutions;

Third, specialized nursing outpatient clinics have been established to provide specialized nursing services, with a focus on delivering comprehensive and continuous care for three population groups—older adults, infants and young children, and pregnant and postpartum women—across four conditions, primarily hypertension and diabetes.

This also aligns with the current policy direction, indicating that the capabilities of primary healthcare institutions are receiving increasing attention, with more medical services to be delivered at the primary care level.

6. Encourage private institutions, such as labor dispatch agencies and domestic service providers, to offer caregiving services

Encourage high-quality nursing resources from secondary and tertiary hospitals to join family doctor contract teams, providing specialized nursing services to community residents. Support nursing homes, nursing centers, and primary healthcare institutions in vigorously developing day care, home hospital beds, and home-based nursing services, thereby delivering home nursing care to individuals who are bedridden for extended periods, patients with advanced-stage cancer, elderly persons with limited mobility, persons with disabilities, and other populations suitable for receiving medical nursing care in a home setting.

Encourage qualified labor dispatch agencies, domestic service institutions, and other entities to actively develop life-oriented services in the nursing field, expanding offerings such as daily living assistance, medical registration and medication pickup, accompanied medical visits, assistive device rental, and home-based care.

This key component should be viewed in conjunction with the vigorous development of the nursing care industry. The Guiding Opinions encourage localities to leverage relevant science and technology funds, special construction funds, and industrial investment funds to support the development and innovation of nursing, rehabilitation, and daily living assistance products, supplies, equipment, and facilities tailored to the characteristics of diverse population groups. By leveraging local conditions and distinctive advantages, efforts should be made to cultivate a cohort of industries related to nursing care products, supplies, equipment, and facilities, thereby meeting the public’s diversified health needs.

Appendix: Original Text of the Notice

http://www.nhfpc.gov.cn/yzygj/s7659/201807/1a71c7bea4a04d5f82d1aea262ab465e.shtml