Research on the Performance and Trust Status Parties in Contract Services of Family Doctors in the Suburbs of Beijing

Background: Family doctor contract service is an important instrument to carry out the hierarchical medical system in China. As the capital of China, Beijing's family doctor contract services are leading the country. This study aims to research the status of family doctor contract services in the suburbs of Beijing, the contract awareness, the degree of trust and the emerging ethical problems between doctors and patients, so as to evaluate the inuences of the contract awareness and trust degree of the contract parties on the subjects’ renewal intention. We expect to explore the feasible ways to solve the obstacle to building doctor-patient mutual trust in family doctor contract services in the suburbs of Beijing. Methods: First, the members of the research team analyzed the statistical data on the services contracted by family doctors. Then, we applied the multi-stage stratied random sampling method to chose a sample of 202 medical staff in the family doctor teams and 197 residents from 4 suburb areas in Beijing. A semi-structured individual in-depth interview method was used to conduct face-to-face interview with 36 medical staff in the family doctor teams. Results: The number of teams and personnel contracted by family doctors has increased year by year, and the resident contracting rate has slowly increased since then a decline in 2015. In 2018, the contracting rate of residents dropped. In that year, the average contracting rate for family doctor services in Beijing was 33.86%. The self-evaluation of the contracted residents on the family-doctor signing service system shows that only 68 (34.5%) contracted residents know a lot about it, while 11 (5.6%) signed residents said they did not understand the system at all. Thirty-two percent of the medical staff surveryed by the questionnaire said the attributes of the relationships between the two parties was a trust relationship, but 50.5% of the medical staff and 68.0% of the contacted residents still said that the nature of both parties just was a relationship of diagnosis and treatment. In addition, only 16.3% of the contracted residents are active in performing the contract, and 2% of the signed are very active. From the perspective of medical staff in family doctor teams, the contracting residents' trust in family doctors’ contracting services and medical staff is underestimated. Moreover, for maintaining a long-term and stable contracting service relationship, the willingness of the residents is


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Background In the 1980s, the concept of general practitioners was introduced in China, and the family doctor system has gradually developed fast since then [1]. It was a primary goal of the reform of the medical and health care system that everyone could realize the accessibility to basic medical and health services, pointed out by the Opinions of the CPC Central Committee and the State Council on Deepening the Reform of the Medical and Health Care System on March 17, 2009. [2]. Afterwards, in the development of communitybased health services in Beijing, Shanghai, Wuhan and other cities in China, had put forward the idea of "family doctor" services successively [3].Beijing, as one of the rst pilot areas of family doctor contracting service systems in China, began to providing family doctor contracting services since 2010. And in 2011, there were 1.485 million-contracts signed in Beijing, reaching it's peak in 2014, with 9.245 million contracts signed. Later, under the program of "improving quality and reducing weight", Beijing paid attention to raising the contract quality and gradually expanded key groups under such contracts [4]. In 2017, the number of contracting residents in the city reached 8.654 million [5].Then in 2018, due to ful lling policy of population demobilization, Beijing's oating population was decreased, and so was the number of it's family doctors dropped accordingly. The number of the city's contracting reached 7,294,100, with a head bene t of 8.45 times each person [6].
As the capital of China, Beijing is equipped with unique medical resources, and its community-based community health services also take the lead in the country. In 2018, 336 community health service centers and 1586 community health service stations had performed in a normal model in the 16 Districts of Beijing. The community-based health services had 37464 staffers, 31163 of whom are health technicians. The number of consultations and treatments in community health service organizations in the city reached 65.691 million, and the number of people served by family doctors was 61.648 million [6]. However, such problems as insu ciency in the supply capacities of primary medical and health service institutions, the number of family doctors and the strength of supporting policies caused a big gap between the provision of family doctor contracting services and the expectation of residents. The lack of contract formations for family doctor contracting services is often criticized by residents. So it is di cult to preserve the mutual trust between family doctor service teams and residents.
The existing researches mainly focus on trust between doctors and patients, but discussing institutional trust is limited to the theoretical level. Still, most researches pay litter attention to doctor-patient trusts in suburban area. There are speci c geographical environments, population composition, environmental supports (including network, communication and transportation), and other conditions in the suburbs of Beijing. In fact, the trust between doctors and patients for such services in the suburban areas is special. Therefore, it is necessary to carry out this research to explore related.
China is at a stage of deep reform the medical and health care system while developing it health care. The mountainous region of Beijing cover an area of 10,200 square kilometers, accounting for about 62% of the total. Meanwhile, the population density in the suburbs of Beijing is smaller than that in the urban area, so the medical resources in the suburbs are much scarcer than in the core areas of urban [7]. In other words, the radius of medical services in the suburbs of Beijing is large. In 2018, the service radius of community health service centers in the mid-mountainous region of Beijing and suburban plains were 12.4 km and 4.8 km, respectively. In contrast, the radius of community health service centers in Beijing's urban plains was only 2.3 km. he average service radius of Mentougou District, Huairou District, and Miyun District all exceeded 12 kilometers [6]. It is an ideal case to study the doctor-patient problems arising from signing a family doctor's contract service.

Data Collection and Measures
This study used multi-stage strati ed random sampling method. In the rst stage. Two areas each with a family doctor's contract service bene ting above and below Beijing's average level were selected in Beijing. They are Mentougou District, Miyun District, Huairou District and Daxing district. In the second stage, we selected about 1/3~1/4 of the townships in layers in each selected area. Finally, according to the contract les of family doctors proved by community institutions, randomly select the contracted residents at the selected township community health service centers as the questionnaire survey objects. Meanwhile, 50%~60% medical staff who have joined the family doctor service team are also chosen as questionnaire respondents. One general practitioners, one nurse and one preventive health care personnel were randomly selected to in the in-depth individual interview. Inclusion criteria for residents: (1) permanent residents within the jurisdiction; (2) residents who have signed the "family doctor signing service agreement" with community health service agencies. Inclusion criteria for medical staff:Community health workers who join the family doctor service team and provide family doctor contracting services.
The research team found out a rigorous review and oversight procedures to ensure the quality of the investigation. All respondents were guaranteed the right to remain anonymous and refuse to join during interviews and analyses. The Ethics Committee of Capital Medical University approved this study. At the beginning of the interview, each subject received informed consent. After the interview, each survey participant in this study obtained informed consent. After the interview, each subject received a survey gift.
In this study, from July to September 2017, a group of trained investigators conducted structured questionnaires and semi-structured personal in-depth interviews in 4 regions selected in Beijing. Two hundred and two family doctor team medical staff and 197 residents engaged in the questionnaire survey, and 36 family doctor team medical staff joined in the in-depth individual interview. Questionnaire survey questions include the socio-demographic characteristics of the contracting parties, the cognition of the family doctor contracting service system the attributes of doctor-patient relationship. And the compliance behavior and initiative of both parties. From the perspective of the contracting parties, the level of trust and interpersonal trust of residents in the contracting services of family doctors, and the willingness of the contracting parties to continue to sign contracts, etc. Personal in-depth interview questions include evaluating the performance of the contracted residents by the medical staff of the family doctor team and evaluating residents' institutional and interpersonal trust in family doctor contract service.
Preparing the questionnaire is divided into three steps: Firstly, literature research had generated the items of questionnaire. Secondly, we used a formal consensus process based on nominal group technology (NGT) to evaluate it [9]. After completed the questionaire , we conducted a preliminary survey on 50 medical staff members of the family doctor team and 50 contracted residents in Mentougou and Huairou Districts. The internal consistency reliability (Cronbach's a) of the signed residents questionnaire was 0.802, and the internal consistency reliability (Cronbach's a) of the medical staff questionnaire was 0.831. At the same time, the surface validity and content validity of the questionnaire are veri ed by health statistics experts and health professionals. The results showed the questionnaire had good reliability and validity.
Compiling the interview outline is divided into two steps: Firstly, the existing research results were reviewed and the preliminary outline was made under the guidance of health management and medical ethics experts. Secondly, we use this outline to conduct pre-interviews with the 3 family doctor team medical staff. After discussing the interview results and the interviewee's feedback with experts, the interview outline was further revised and improved to form the nal interview outline.

Statistical Analysis
We set up the questionnaire survey by using Epidata 3.1 software to gain the data, and we calculate the mean value of measurement by using SPSS 19.0. The count data was analyzed for composition ratio, frequency description, and ranking. We compared and analyzed the data of the two groups , and P<0.05 was considered statistically signi cant. Also, we adopted the thematic frame analysis method for the texts of personal in-depth interview, the core of which is to settle "thematic framework". It mainly includes two major steps of data collation (including xing the subject framework, data labeling and classi cation) and analysis. Ensure the integrity and transparency of data processing and analysis.

Socio-demographic characteristics of the respondents
In this study, 216 medical staff members of family doctors were included in the research questionnaire.
Incomplete data were eliminated, 202 valid respondents (effective recovery rate was 94.4%).
Among the medical staff interviewed, 25  A total of 36 family doctors were included in this in-depth individual interview. The youngest was 28 years old and the oldest was 56 years old. The average age of these family doctors was 39.36 ± 6.74 years.
Among the 36 family doctors, the shortest working time was 1 year and the longest was 36 years. The average working time of these family doctors was 12.9 ± 8.2 years. The professional and technical titles of family doctors account for 5.6% of the overall ranks, the division accounted for 27.8% of the total, the intermediate accounted for 36.1%, 10 deputy chief physicians, accounting for 27.8% of the total, and 1 chief physician, 1 proportion 2.8%.
The cognition of both parties to the contract service system of family doctors The self-assessment status of both parties' cognition of the family doctor contracting service system shows that 163 (80.7%) family doctor team medical staff and 68 (34.5%) contracted residents suggested they have higher awareness of the family doctor contracting service system (Learn more and much). 5 (2.5%) family doctor team medical staff and 31 (15.7%) contracted residents showed little understanding. Eleven (5.6%) of the residents who signed up said they did not know anything about the system(see table   3 for details). The channels for residents to understand the contract service system of family doctors are mainly through the publicity of community medical staff, introduction of rural doctors and TV publicity. The attribute cognition and contract consciousness of both parties to the doctor-patient relationship Regarding the cognition of the medical staff of the family doctor team on the relationship between the contracted residents and themselves, 50.5% of the medical staff of the family doctor team stated that they had a diagnosis and treatment relationship with the contracted residents, 31.2% said that they had a trust relationship, 17.3% of the family doctors said to propose a relationship, only a few (1.0% of the medical staff of the family doctor team) consider the contracting parties to be an economic relationship.
As shown in table 4, the residents who signed the contract sugguested that a large percentage of medical staff performed better (46.2%) and very good (28.9%). Moreover, they were more proactive (46.7% of the family doctor team medical staff were more active, 36.0% Medical staff are very proactive). In the personal in-depth interviews with the medical staff of the family doctor team, the medical staff stated that the medical staff of the family doctor team performed well (61.1%), but the compliance of the residents who signed the contract was not high (41.7%). For example, in the interview, a medical staff member of Miaofengshan community health service center in Mentougou District said, "The performance of medical staff is quite good. Our community health service center has been conducting family medicine for several years. Everyone slowly understands this model and recognizes it. The situation is still good, and we provide preferential policies to contracted residents, give priority to service contracted patients, regularly invite experts to give lectures, free consultations, and call the contracted residents to inform.Said a medical worker at Taishitun community health service center in Miyun District. "Residents' performance is relatively poor, because their educational levels are uneven." You might make an appointment with him in the morning, he'll come in the afternoon. They are often not punctual." Residents' system of contracting services to family doctors and interpersonal trust from the perspective of both parties The questionnaire survey shows the residents of the family doctor team from the perspective of medical staff trust the system and medical staff generally lower than the degree of trust from the perspective of contracted residents. From the perspective of resident, the degree of trust in the family doctor contract service system and the moral trust in the medical staff of the family doctor team are both over 80% (including higher and higher trust) and 79.2% in their abilities. From the perspective of family doctor team medical staff, contracted residents have a low trust in the system of contracted services of family doctors. Only 20.8 percent of medical workers said that residents who signed up had a high trust in the system. Among them, 68.6% and 80.2% of the contracted residents have trust in the ability and ethics of the medical staff of the family doctor team respectively (including higher and higher trust).

Table5
The system and interpersonal trust of residents to the contracted services of family doctors from the perspective of contracting parties The continuing willingness of both parties to sign Among 202 family doctors surveyed, 8 (4.0%) were unwilling (including "very unwilling" and "relatively unwilling") to maintain a long-term and stable contractual service relationship with contracted residents, 57 (28.2%) were in general, and 137 (67.9%) were willing (including "relatively willing" and "very willing").
Among the 197 contracted residents who involved in the questionnaire survey, 7 (3.5%) are not willing to (including "very unwilling" and "relatively unwilling") keep long-term stable contractual service relationship with contracted doctors, 16 (8.1%) were in general, and 174 (88.3%) are willing (including "relatively willing" and "very willing"). Further analysis revealed there was no statistically signi cance in the difference between the two parties to the question. The willingness of contracted residents to uphold a long-term and stable contractual service relationship with family with family doctors is signi cantly higher than that of family doctors. See

Discussion
Analysis of problems existing in the contract services of family doctors in suburban areas of Beijing First, in the process of family doctor contracting service, the family doctor service team should sign an agreement with the serving family (residents) under the principles of full noti cation, voluntary contracting, free choice and standardized service and establish a relatively stable contract service relationship with them [10] . However, according to the eld investigation of this research group, the current method of signing services for family doctors in suburbs of Beijing is to sign by slicing. Therefore, the residents' free choice has not been implemented. The slicing contract is based on the consideration that the family doctor service team is understaffed and easy to manage, but it is di cult to achieve the expected results during the implementation process. The signing autonomy will have a great impact on the performance situation and enthusiasm of the signing residents in the later period [11]. On the one hand, involuntary choices make it di cult for contracted residents to actively understand and seek health services [12]. On the other hand, the non-competitive contracting method will also limit the quality of services provided by the medical staff of the family doctor's contracted service team [13]. Therefore, how to maximize the autonomy of contracted residents under the premise of guaranteeing the management effect and performance is still an important issue to be considered by current family doctor contracting services.
Second, the change of the health-seeking behavior of the contracted residents can be divided into three continuous processes: knowledge acquisition, belief generation and behavior formation. To achieve the ultimate goal of the performance it must be based on cognitive ability [14~16]. At present, contracted residents have insu cient understanding of the contract service system of family doctors, it will greatly affect their health seeking behavior [17]. According to the survey results, there are still residents who do not understand the family doctor signing system (5.6%), which is closely related to the cognitive ability of residents. 33.5% of the residents interviewed this time have a primary school education or below, 5.6% of the resident respondents are over 75 years old. And education and seniority are important reasons affecting residents'cognition [18]. At the same time, the medical staff of the family doctor team do not have a deep understanding of the family doctor contracting service system. The World Health Organization stated primary health care is the backbone of the health system [19]. Family doctors, as practitioners of the family doctor contracted service system and the gatekeeper of residents' health, have not reached the expected degree to understand the family doctor contract service system. 2.5% of the medical staff said they had little understanding of the contracted service system of family doctors, and 16.8% of the medical staff self-assessed they had a general understanding of it.
There is a great gap between the suburban and the urban to promote and conduct family doctor contracting services. However , the signing rate of contracting services of family doctors by Beijing municipal health administration departments should be uni ed in all districts. The workload and pressure of subscribing to family doctors in rural areas has been increased, and the number and ability of suburban health personnel is inadequate. Under this situation, it is di cult for family doctors to provide high-quality family doctor contracting services.
The contract performance and trust status of both parties of family doctors in the suburbs of Beijing According to the results of questionnaire survey and individual interview, the medical staff of the family doctor team have a strong sense of compliance, and good performance and initiative. The residents who sign the contract have a better performance, but have less compliance. Thus in addition to providing basic medical and health services and contract services, the medical staff of the family doctor team should also supervise the contracted residents ful ll their contracts in time. It is found in the survey that 44.7% of the respondents are close to the community health service center (less than 15 minutes on foot), and 38.1% of the contracted residents have a great demand for medical treatment (more than 12 times of medical treatment in the community health service center last year). As the tra c in the suburbs is relatively inconvenient, it has a greater impact on the enthusiasm of residents who sign contracts and ful ll the contract with relatively long distance and low demand for medical treatment. Overall, the consciousness of contracted residents is not strong, the signing of the family doctor's contracted service agreement is di cult to promote compliance awareness and behavior.
The cognition of the attributes of the two contracting parties shows that although most of the contracting parties said that the relationship between them was a diagnosis and treatment relationship, more than one-third of the residents considered it to be a trust and intended family relationship. Nearly half of the medical staff is expressed as the trust relationship and intended family relationship. It can be seen that the family doctor contracted service system transforms general medical staffs into family doctors, which makes the trust model of doctor-patient relationship in community health service institutions gradually change from the acquaintance society into everything bound by rule. [20].
In 1980, Olive proposed Expectation Discon rmation Theory, which described the numerical measurement of tting degree between actual observation result (P) and theoretical expectation result (E). When P>E, the actual observation results are higher than expected, and consumers are satis ed [21]. Because residents have a little knowledge to the family doctor contracting service system, they have low expectation and high trust to the medical technology in the community health service institutions. From the perspective of the medical staff in the family doctor team, the trust of residents in the contracted service system of family doctors is underestimated. Then, the positioning of community health service institutions is in con ict with the Chinese residents' concept of "no medical treatment for minor diseases, specialists for serious diseases",which leads to the demand for contracted residents' medical and health services in community health service institutions as community medicine and referrals. In this process, the space for interpersonal trust interaction between the contracted residents and the family doctor is limited , which has yet to reach the trust level. the requirements on the quantity and quality of the contract, their performance appraisal will be re ected rstly, then this will also affect the evaluation of their working ability by the contracted residents and their superiors. At this time, the problem of the imbalance between efforts and returns has generated based on environmental reasons (imbalance between pay and return) and personal causes (excessive responsibility) [22]. Literature studies show that family doctors' team medical staff have a low sense of organizational fairness [23]. Medical staff may take actions to reduce their workload, and quality of work life to relieve this injustice [24][25].
Countermeasures and Suggestions on the sustainable development of family doctor contract service system Both the government and family doctors should fully respect the signing autonomy of residents. Respect for the principle of autonomy fundamentally re ects and protects the health rights and interests of patients, which is an important content to re ect the life value and personal dignity of patients [26]. As a speci c idea of doctor-patient relationship and ethics, respect for patients' independent choice rst underlines patients' sense of autonomy, which is the forerunner of behavior [27]. It is a prerequisite to provide contract services for family doctors and guide residents to sign contracts on their own initiative. In order to facilitate management, in 2016, the medical reform o ce of the state council issued the notice on the issuance and promotion of guiding opinions on contracting services for family doctors, which mentioned that "according to the service radius and service population, the contracted service responsibility area should be reasonably divided" [28]. This part of the content is understood by some areas as dicing-type signing. That is, a village can all sign the same family doctor team. In fact, this contract service is di cult to guarantee respect for the autonomy of residents in signing contracts.
Therefore, relevant government departments should take a full consideration to the principle of respect for autonomy in policy-making, and strictly de ne the speci c methods for family doctors to sign services.
Residents shall strengthen their awareness and initiative to ful ll their duties, and the cost of breach should be clearly stipulated in the agreement. For example, free physical examination, appointment for medical treatment and referral services are no longer provided for contracted residents without affecting their health. In this way, we can restrain the behavior of contract residents and improve the effective utilization of medical resources. At the same time, the active contracted residents will gain incentives, such as free physical examination, referral and interrogation of the experts. Foreign experience can also be used for reasonably de ning and standardizing the content of family doctors' contracted service items [29][30][31], reducing the non-medical workload of family doctors' medical staff [32], narrowing the gap between supply and demand [33], and improve the sense of gain of both doctors and patients.
According to the different geographical topography and tra c conditions in Beijing, especially the difference between the suburbs and the urban. The contents and methods of services provided by family doctors in contract services should be reasonably planned in line with the local conditions. The number and scope of contracted services should be reasonably determined based on the population composition, service radius and distribution of medical resources. Related medical institutions should relieve family doctor team medical staff from working overload. At the same time, more preferential policies should be adopted to increase the attractiveness of family doctor positions to medical college graduates in terms of salary level, working environment and promotion mechanism. In addition, each family doctor service team is equipped with an assistant position to assist the team in non-medical work such as publicity of family doctor contract service, record entry management and supervision of performance.
The government and relevant departments should innovate the publicity of family doctor contract services through multiple channels. In terms of propaganda, they should not confuse the content of family doctor service and the content of other work in community health. It is necessary to highlight service main body and expand the contracted residents' konwledge to the contracted service of family doctors. In the form of publicity, according to the characteristics of contract groups, they should pay attention to direct publicity of language and video transmission mode. In the selection of publicity space, it is necessary to break through the geographical limitations of community health service institutions and the community should be used for publicity in order to achieve the best publicity effect.

Conclusions
This survey and interviews will help the industry understand the problems existing in imposing family doctor contracting services with Chinese characteristics. Studies have shown that the current contract service mode of Beijing family doctors has, to a certain extent, hindered residents' trust in the contract service team of family doctors and their willingness to continue to sign. How to respect the autonomy of contracted residents is a key ethical issue needs to be considered in forming China's medical and health service system. There is still a long way to improve the performance and enthusiasm of the contracting parties and heighten the trust in the family doctor contract service system way to go. The government and relevant departments must immediately take feasible measures to reduce the ambiguity of policy terms and ensure the implementation of two-way incentives for both parties.
This research adopts a descriptive research method to describe the relevant performance and trust status of both parties. We still have not determined the causal relationship just through cross-sectional investigations. It may be di cult to be objective, despite efforts to avoid conclusions that are too subjective. In the future, it is still necessary to update and supplement relevant data through continuous and in-depth investigation, so as to provide more decision-making references for improving the operation recommendations of family doctor contract service model.