The integration of medical care and prevention is an important measure for the implementation of the Healthy China Strategy. Family doctor teams as the mainstay and chronic disease management as the entry point are important tools for the implementation of the medical and preventive integration in primary health institutions.

To understand the current situation and obstacles of the integration of medicine and prevention in chronic disease management in Beijing urban areas, so as to provide a basis for decision-making on sustainable development of the medical and preventive integration services.

From December 2023 to February 2024, the purposive sampling was used to invite 20 participants, including the members of the family doctor teams and primary care managers working on the the medical and preventive integration and the chronic disease management in 12 primary health institutions in the urban area of Beijing, to conducted semi-structured interviews focus on the content, division of labour, resource allocation, and existing problems of above services. Thematic analysis was used to analyse and generalise the interview data.

Although the primary health institutions had explored a variety of service modalities to promote the implementation of the integration of medical care and prevention. The qualitative research showed that the main body of the current service was still the general practitioner and the community nurse, and continued the kernel of the chronic disease management service, with the content of the service yet to be innovated, and the service process of pre-consultation, consultation, and post-consultation yet to be promoted. In terms of the operating environment, there were insufficient members of the family medicine team, heavy workload, emphasis on "quantity" rather than "quality" in assessment and evaluation, "information silos", lack of top-level design, and lack of a special funding mechanism. The phenomenon of "medical and prevention fragmentation" is obvious, with the existence of "two lines" of the management systems, "two disconnections" between the main bodies, and regional dispersion of work areas of the medical and preventive integration.

Due to insufficient resources allocation and optimisation of the operation mode, it's necessary to strengthen talent training, reinforce medical insurance support, accelerate information sharing within the region, improve assessment and evaluation mechanisms, as well as strengthen the top-level design, clarify the service pathway, implement community functions, and form a replicable and scalable integrated service model with the participation of the government, community, hospitals and patients.