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The NHS
国民健康保险制度
Health reform in a cold climate
遇冷的医改
The government's reforms to the NHS are viewed as its biggest failure. They are better than that
政府医改被指其最大败笔。“盛名”之下其实难副
“WITH the Conservatives there will be no more of the tiresome, meddlesome, top-down restructures that have dominated the last decade of the NHS.” So said David Cameron in 2009, and many were convinced. Voters made Mr Cameron prime minister in2010 inpart because the Conservative Party cut into Labour's lead on health care, which it had enjoyed almost since it founded the NHS in 1948. The Tories quickly squandered their advantage. But their legacy will be better than they seem to believe.
“有了保守党，NHS（National Health Service 英国国民健康保险制度）近十年主要的恼人、好事、专制的医疗结构会一扫而光”，这是英国首相卡梅伦在2009年说过的话，且广受信服。2010年，选民把戴维·卡梅伦选为首相，有部分原因是因为保守党插手了工党主导的医疗保健项目，这个项目几乎自从1948年设立了NHS就赞誉颇多。然而保守党很快就把优势糟蹋一空。但“遗产”比他们大部分人认为的要丰厚。
In spite of his promise, Mr Cameron's Conservative-Liberal Democrat coalition government embarked on reforms that would reshape the NHS from the top down. The immense Health and Social Care Act of 2012 increased competition, gave the service greater autonomy and put more decisions about the purchase of care in the hands of local doctors, known inBritainas general practitioners, or GPs. The changes were so big that they could be seen from space, quipped Sir David Nicholson, the departing head of the NHS.
即便是承诺在前，卡梅伦领导的保守党和自由民主党联合政府着意的改革仍将自上而下的改造NHS。2012年，声势浩大的医疗社会保障法案使竞争更加激烈，给医疗服务业更大的自主权，以及把决定医疗开销的权利交由本地医生掌握，这类医生在英国被称为全科医生，简称全医。NHS前主管戴维·尼克尔森爵士曾调侃，这么大的变革，在太空都能看到。
The government soon came to wish they would disappear. The reforms were never popular with a bemused public. Doctors' groups argued they would lead to a more fragmented and privatised system. Others worried that GPs would be incapable of commissioning care. Ed Miliband, Labour's leader, dubbed the reforms Mr Cameron's “poll tax”, a reference to the policy that helped fell Margaret Thatcher. In this case it was Andrew Lansley, the health secretary, who fell. Less than six months after his reforms were passed, Mr Lansley was replaced by Jeremy Hunt, who talks about them as little as possible.
很快，政府就希望这些变革能尽快消失。迷惑的民众并不欢迎这些改革。医生群体称，这个权利会让他们最终导致一个更加零碎化、私有化的医疗系统。还有人担心，全科医生并没有能力被委任护理。工党领袖埃德·米利班德把这些改革戏称为卡梅伦的“人头税”，一个曾经让撒切尔夫人下台的参考政策。而现在，下台的是卫生部长安德鲁·兰斯。兰斯的改革通过不到六个月内，他就被杰里米·亨特代替了，而后者几乎对改革只字不谈。
The health reforms were supposed to make the NHS more independent. Yet Mr Hunt now styles himself a patients' champion—he is known to ring hospitals to ask about waiting times. This is a concession to reality: politicians will always be held accountable for the performance of the NHS. Still, the frantic smothering of the reforms conceals something useful. A policy that has caused the government so much embarrassment is quietly bearing fruit.
医疗改革旨在让NHS更加独立。然而杰里米·亨特现在自比为病人的胜利，因为大家都知道他常常打电话给医院询问等待时间。这是承认现实：政客永远要为NHS的表现负责。但是，改革密不透风的大动干戈掩盖了一些有用的东西。一个让政府非常窘迫的政策正静悄悄地开花结果。
Let 211 flowers bloom
让211之花盛开
The biggest change was the creation of 211 Clinical Commissioning Groups (CCGs), which placed about 60% of the NHS budget in the hands of local doctors and health workers. They became responsible for procuring hospital care, mental-health services and the like. Navigating a muddled system, the cannier ones have figured out ways to realign the incentives of hospitals, which are often paid per procedure, with those of GPs, who aim to keep people healthy and at home.
最大的改变是211临床调试组（CCGs）这一创举，收纳了本地医生和医务人员手中60%的NHS预算。调试组负责采购医院护理、心理健康护理之类的物品。游走在混乱的医疗系统中，头脑灵活的人已经想出办法调整对医院的刺激，这些在每次采购中都会被全科医生偿付，他们旨在使病人保持健康，觉得自在。
The commissioning group in Bedfordshire, for example, has bundled some 20 contracts for musculoskeletal care (treatment for things like weak knees and cracked hips) into one five-year contract that was won by Circle, a commercial health group. Far from fragmenting the system, as critics had feared, this has made Circle responsible for integrating the services of local providers. Patients will be told which are doing best. Circle and its partners must achieve an agreed set of outcomes to receive some of their pay. Paolo Pieri, Circle's chief financial officer, expects the deal will not only improve care but save Bedfordshire some ￡30m($50m).
例如英格兰南部贝德福德郡的调试组，已把20余份关于肌肉骨骼保健（面向脆弱的髌骨和股骨骨折之类的治疗）的合同与一份五年期的合同相捆绑，这份合同被商业医疗集团Circle中标。批评家们曾经担心的医疗系统会分崩离析的问题使Circle必须负责，这能使Circle为本地供应商的集成服务负责。病人将会被告知哪个做的最好。Circle及其合伙人必须就后果及分利达成共识。Circle的CFO（首席财政官）保罗·皮耶里希望，这笔交易不仅仅能够改善卫生保健，还能为贝德福德郡留下约3000万英镑（约合5000万美元）的结余。
Not all commissioning groups are as bold. But perhaps a quarter are considering contracts like the one in Bedfordshire, reckons Mr Pieri. Diane Bell, a doctor there, says more than 40 CCGs have contacted her group. “Every CCG I look at is doing brave and innovative work,” says Shane Gordon, who heads one inEssex.
并非所有调试组都能这般大胆无畏。皮耶里推测，约有四分之一的调试组正考虑像贝德福德郡那个一样签订合同。贝德福德郡的一位医生戴安娜·贝尔说，有超过40家临床调试组与她的团队签订了合同。肖恩·戈登在埃塞克斯郡领导一个调试组，他说“每个临床调试组在我看来都在从事勇敢无谓、富于创新的工作”。
The Labour Party—which launched a series of NHS reforms during its 13 years in power—says this sort of innovation was on the way anyway, and may have been delayed. Thanks to the giant restructuring of the NHS “we lost two or three years”, says Andy Burnham, the shadow health secretary. He also criticises a regulatory regime that leaves many providers confused. Fair enough. But the reforms replaced bureaucrats with clinicians, which seems to have encouraged creative thinking. Dr Bell was warned by an old hand that outcomes-based contracting would stir up a fight in her group. When she suggested it, though, the other GPs quickly bought in.
工党在其执政的13年间，曾颁布了一系列NHS改革，它称这类改革创新不管怎么说都已经在半路上了，还有可能推迟。影子卫生部长安迪·博翰讽刺，幸亏这次NHS巨大的改革让我们“浪费两三年”。他还批评监管制度让许多供应商迷惑不解。虽有道理，但是改革用临床医生代替了官僚分子，似乎还鼓励了创造性思维。贝尔医生曾被这行老手告诫这个以结果为基础的契约签订可能引起团队内讧。尽管当她提到了这个，全科医生还是被迅速引入了。
If Labour wins the next election, Mr Miliband might ground CCGs just as they are taking flight. Although he has no plans to restructure the NHS yet again, his laudable aim of integrating health and social care, which currently falls outside the NHS's remit, would probably shift responsibility to a different local body. Mr Burnham would also clip the wings of reformers by giving NHS providers a built-in advantage in the competition for contracts.
下届大选如果工党获胜，米利班德可能搁置临床调试组，正如现在他们才刚刚起航。即使他没有再次重组NHS的计划，他值得赞赏的集成医疗社会保障计划目前还处于NHS的推迟项目，很可能把责任转移到一个不同的地方机构。博翰也会通过给予NHS供应商先天优势的方式，限制改革者在签订合同方面的竞争。
But the biggest threat to CCGs and what some of them are doing to improve services is not politics but whether they can move fast enough to keep in front of a funding squeeze, says Thomas Cawston of Reform, a think-tank. Though the NHS has been protected from the worst of austerity, it could fall short by ￡30 billion by 2020—the result of rising demand from a growing elderly population. Sir David warns that without more cash, the service could tip into the red next year.
智囊团Thomas Cawston of Reform称，对于临床实验组最大的威胁，以及其中部分改善服务所作的努力不是来自政治方面，而是他们是否可以发展的足够快是实验组一直保持在资金压力前面。尽管NHS被最糟糕的财政紧缩保护，但其资金到2020年还不到300亿英镑，这是不断增长的老龄人口日益增长的需求带来的结果。戴维·尼克尔森爵士警告道，没有更多的钱，这项服务明年就会陷入危机。
As money runs short, the real test will arrive. It could be an opportunity for health reformers. Or bureaucrats could panic and revert to old ways. Whatever happens, the next government will not be able to duck the issue.
随着资金短缺，真正的考验即将来临。这对医改人士而言是一次机遇。那些官僚却可能会陷入恐慌，且想要回归老路。无论发生什么，下届政府都无法回避这一问题。译者 周雨晴 校对 邵夏沁
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