This mixed-methods study explores the language-related difficulties and ELT support offered in English-medium programmes at eight universities in China. Data included a student questionnaire (n = 394) measuring the difficulties of 45 academic tasks, organized around the four skills of reading, writing, listening, and speaking. Results revealed students faced the largest difficulties with productive skills, especially writing. To explore structural language support for overcoming such challenges, fieldwork interviews with twenty-six senior faculty at eight universities in four cities in China were conducted. These revealed three main types of institutional support: concurrent language support from English language teachers offered alongside English medium programmes; preparatory programmes taken before students enrolled in English medium courses, which were prevalent in language-specialist universities; and self-access learning and writing centres, which were found at two transnational universities. When structural support was lacking, content teachers reported making grassroots efforts to help students understand content via use of the students' multilingual repertoires in explanations, interactions, and materials.