Abstract: The advancement of high-quality national basic public health services continues to faces critical challenges，including insufficient quality resources in primary care and limited diagnostic and treatment capabilities. Since January 2022，Longhua District，Shenzhen initiated a pilot of the digitally enabled GP-Specialist Collaborative Care Model，aiming to enhance the capacity of primary healthcare service in managing hypertension and diabetes. This initiative leveraged the national basic public health services platform and the integration of medicine and prevention. Through policy guidance，system development，and digital support，the model seeks to facilitate the efficient distribution and utilization of quality medical resources. This study presents the practical experiences of implementing the model from three key dimensions：policy mechanisms，practical measures，and early achievement. The preliminary practical achievements include：（1）Patient monitoring and enrollment：from 2022 to 2024，the proportion of hypertensive patients enrolled due to two consecutive instances of poor blood pressure control within six months was 35.3%，37.5%，and 36.2%，respectively；the proportion of diabetic patients enrolled due to two consecutive instances of poor blood glucose control within six months was 55.5%，64.0%，and 47.5%，respectively.（2）Specialist consultation：the timely consultation rates for hypertension and diabetes increased by 46.3% and 53.9%，respectively，in 2024，as compared to 2022，following the inclusion of the timely consultation rate in the performance evaluation of the medical consortium at the end of 2023.（3）Implementation by general practitioners：between 2022 and 2024，the timely implementation rate for hypertension increased from 73.7% to 84.3%，and for diabetes，from 73.9% to 80.8%.（4）Outcomes of patients managed by general practitioners and specialists：the average control rates during 2022 and 2024 for enrolled patients with hypertension and diabetes were 57.1% and 50.9%，respectively. The pilot experiences indicate that the digitally enabled GP-Specialist Collaborative Care effectively improves the management capacity of hypertensive and diabetic patients in primary care settings，contributing to better patient outcomes. At this critical juncture in advancing the high-quality development of national basic public health services，it is essential to establish implementation standards，strengthen supporting policy mechanisms and implementation strategies，and optimize the assessment and evaluation framework for basic public health services. These steps are vital to ensuring the successful nationwide adoption of this innovative policy model.

Key words: Public health, National essential public health services programs, Chronic disease management in primary care, General practice-specialty collaborative care, E-health, Implementation achievement

摘要： 国家基本公共卫生服务高质量发展面临基层优质资源不足、诊疗水平有限等瓶颈问题。深圳市龙华区根据医防融合工作部署，依托基本公共卫生服务项目，自2022年1月起探索试点“数字化+健康管理”全专协同服务模式，以提升基层高血压和糖尿病健康管理服务能力为核心目标，通过政策引导、体系建设和数字化支撑，实现优质医疗资源有效下沉和高效利用。本文从政策机制、具体措施以及初步成效3个方面探讨数字化赋能全专协同服务的实践经验。初步成效包括（1）患者监测与入库情况：2022—2024年，深圳市龙华区半年内因连续2次血压控制不满意而入库管理的高血压患者比例分别为35.3%、37.5%、36.2%，半年内因连续2次血糖控制不满意而入库管理的糖尿病患者比例分别为55.5%、64.0%、47.5%；（2）专科医生会诊情况：由于2023年底将专科医生会诊及时率纳入了医疗集团绩效考核评价体系，2024年会诊及时率明显上升，较2022年高血压和糖尿病会诊及时率分别提高了46.3%、53.9%；（3）全科医生执行情况：高血压执行及时率从2022年的73.7%上升至2024年的84.3%，糖尿病执行及时率从2022年的73.9%上升至2024年的80.8%；（4）入库患者管理效果：高血压和糖尿病患者2022—2024年平均达标率分别为57.1%和50.9%。试点经验表明，数字化全专协同服务模式有效促进了优质医疗资源的整合与利用效率，提升了基层健康管理水平，在患者血压、血糖控制方面发挥了关键作用。在国家基本公共卫生服务迈向高质量发展的关键阶段，建议尽快制订数字化全专协同服务的实施标准，健全相关政策助推机制，完善基本公共卫生服务评价管理体系，以期实现政策试点的全面推广。

关键词: 公共卫生, 国家基本公共卫生服务, 基层慢性病健康管理, 全专协同, 数字化, 实践成效