他山之石：2023年5月27日《经济学人》社论（Leaders）精选：《如何改革英国的国民医疗保险制度》（“How to fix the NHS”）

Leaders | The sick factor 

社论 | 致病因素

How to fix the NHS

如何改革英国的国民医疗保险制度（NHS）

Money will help. But a radical shift in focus is more important

资金会有所帮助。但是更为重要的是要实现重心的彻底转移

Britons are prouder of their health-care system than they are of the monarchy. But when the English National Health Service (NHS) turns 75 in July, the mood will not be celebratory. Hospital waiting lists in England spiral beyond 7m, forcing many to wait months or even years for treatment. Almost 300,000 adults are waiting for a social-care assessment. A record 2.5m Britons are out of work because they are sick. NHS staff are leaving the workforce in droves. On basic measures of health, Britain suffers by comparison with its rich-world peers. Its people barely live any longer than they did a decade ago, and have some of the worst survival rates for diseases such as cancer. During the pandemic, the public clapped for the NHS. Now they are more likely to throw up their hands in frustration.

不列颠人对他们的医疗医疗系统比对君主政体更感到自豪。但是，当英国国民医疗保险制度（National Health Service，NHS）在7月份迎来75岁生日时，气氛将不会是喜庆的。英格兰的医院等候名单急剧攀升至700万以上，迫使许多人等待数月甚至数年才能接受治疗。近30万成年人正在等待社会护理评估。创纪录的250万英国人因为生病而失业。NHS工作人员正在成群结队地离开劳动力队伍。在基本健康指标上，与富裕国家同行相比，英国的情况是糟糕的。与十年前相比，它的人民很少能够享受更长的寿命，并且癌症等疾病的存活率是最差的。在新冠流行期间，公众为NHS鼓掌喝彩。（但是）现在，他们更有可能绝望地摊开双手。

When something is broken, the boldest reforms can often seem the most tempting. Some want to overhaul the NHS’s funding model, switching from a system funded by taxation to one based on social insurance, as in France or Germany. Others mull the case for much wider use of means-tested charges. But Britons will not easily ditch what Nigel Lawson, a former chancellor, once called their “national religion” of health care funded by taxes and free at the point of use. And the country’s recent record of revolutionary change does not inspire confidence.

当某些东西被打破时，最大胆的改革往往看起来最诱人。一些人希望彻底改革NHS的融资模式，从税收资助的系统转变为基于社会保险的系统，像法国或德国那样。其他人则考虑更广泛地采用经济状况调查费用机制（“经济状况调查费用”是指通过财务评估或经济审查，以确定理事会是否会为您的护理付费。它首先要看你有多少钱。在英格兰，如果您的储蓄少于23，250英镑，该委员会通常会帮助支付护理费用。从2025年10月起，这将增加到100，000英镑的节省）。但英国人不会轻易抛弃前财政大臣尼格尔·劳森（下图，Nigel Lawson，1932年3月11日—2023年4月3日，英国政治人物和新闻工作者。作为保守党成员，他于1981年至1989年期间在撒切尔夫人的内阁中任职。1983年6月，被任命为财政大臣，一直到1989年10月辞职）曾经称之为他们的“国教”，即由税收资助的医疗保健，并在使用时免费。该国最近的革命性变革记录并没有激发起（人们的）信心。

It is also unnecessary. The recipe for saving the NHS requires radicalism, but of a simpler sort: turning the NHS from what it has become—a sickness service—into what its name promises—a health service. That will mean spending more money. But to spend it productively requires a shift in focus: away from hospitals to the community, from treatment to prevention, from incentivising inputs to encouraging better outcomes.

这也是不必要的。拯救NHS的秘诀需要激进主义，但更简单：将NHS从现在的疾病服务转变为名副其实的健康服务。这将意味着要投入更多资金。但是，要想有效地使用它，就需要将重点转移：从医院转向社区，从治疗转向预防，从激励投入到鼓励更好的结果。

Health already absorbs the biggest single chunk of government spending. Of every pound the state spends on public services, 38p goes on the NHS. But Britain spends less on health care than countries like France and Germany as a share of GDP. It especially skimps on capital spending: no OECD country invests less on a per-person basis. And the demands on the health service are only going to go up. In the next 25 years the number of Britons aged 85 and older is set to double. The NHS is the largest single employer in Europe; the phenomenon of “cost disease” means that the pay of nurses and doctors needs to keep rising to compete with wages elsewhere in the labour market.

医疗卫生已经吸收了政府支出的最大部分。该国在公共服务上所花费的每一英镑中，有38便士（自1971年2月15日实行十进位制后，便士的价值为一英镑的百分之一，即1英镑兑换100新便士）用于NHS。但英国在医疗保健方面的支出占GDP的比例低于法国和德国等国家。它尤其在资本支出方面是吝啬（抠门）的：没有一个经合组织国家的人均投资比它更少。对卫生服务的需求只会上升。在接下来的25年里，85岁及以上的英国人数量将翻一番。NHS是欧洲最大的单一雇主；“成本病”现象意味着护士和医生的工资需要不断上涨，才能与劳动力市场其它地方的工资相抗衡。

The critical question is where the money is spent. At the moment, the answer to that question can be boiled down to one word: hospitals. Spending on public health (covid-19 prevention aside) and social care has fallen in real terms over the past decade. The share of total NHS spending allocated to primary and community care was falling even before the pandemic; the share doled out to hospitals had risen to almost two-thirds. As a share of GDP spent by rich-world governments and compulsory insurance schemes, only America spends more on hospitals.

关键问题是钱花在哪里。目前，这个问题的答案可以归结为一个词：医院。在过去十年中，公共卫生（除了新冠预防）和社会护理方面的支出实际上已经下降。甚至在新冠流行之前，分配给初级和社区护理的NHS总支出份额就在下降；分配给医院的比例已上升到近三分之二。作为富裕国家政府和强制保险计划支出占GDP的比例，只有美国在医院上的支出更多。

This makes no sense. A system focused on hospitals is one designed to treat people only after they have become really sick. That is the equivalent of buying more fire extinguishers while dismantling the smoke alarms. The majority of health and social-care spending now goes on treating long-term conditions like diabetes, high blood pressure and arthritis. Such conditions are managed best by patients themselves, in their own homes and with the support of networks of general practitioners and local specialists. The share of money going to primary care should be restored from 8% of the NHS budget to the 11% proportion it was two decades ago. Social care needs more money, too, and a proper long-term funding plan.

这是没有道理的。一个专注于医院的系统是一个旨在仅在人们病重后才对其进行治疗的系统。这相当于一方面拆除烟雾报警器另一方面又购买更多的灭火器。现在，大部分健康和社会护理支出用于治疗糖尿病、高血压和关节炎等长期疾病。这种情况最好由患者在自己的家中并在全科医生和当地专家网络的支持下进行自我管理。用于初级保健的资金份额应从NHS预算的8%恢复到二十年前的11%。社会护理也需要更多的资金，以及适当的长期资助计划。

The corollary of moving care out of hospitals and into communities is to focus on prevention: keeping people healthy for as long as possible. That means widening the lens on health care. For all the headlines it grabs, medical care contributes comparatively little to the state of the nation’s health: socio-economic factors, genetics and individual behaviour matter more. One obvious example is obesity. Britain is the third-fattest country in Europe; an obese patient costs the NHS twice as much to treat as one who is not. The government needs a more muscular strategy to tackle this problem before it turns up in waiting rooms and hospital beds, for example by making effective use of promising new anti-obesity drugs.

将护理从医院转移到社区的必然结果是专注于预防：尽可能长时间地保持人们的健康。这意味着扩大对医疗保健的视野。尽管它占据了所有头条新闻，但医疗保健对国家健康状况的贡献相对较小：社会经济因素、遗传和个人行为更重要。一个明显的例子是肥胖。在欧洲，英国是肥胖问题排第三的国家；肥胖患者的治疗费用是非肥胖患者的两倍。政府需要一个更强有力的策略来解决这个问题，比如通过有效利用有前途的新型抗肥胖药物。

《经济学人》2023年5月25日文章链接：病房思维——为了生存，英国的NHS必须停止关注医院护理；社区护理才是增进健康的途径

(https://www.economist.com/britain/2023/05/25/to-survive-britains-nhs-must-stop-fixating-on-hospital-care)

The way that the NHS measures and motivates performance also needs to change. At the moment, the system is geared towards inputs. Politicians conventionally compete to make promises about the number of new hospitals or the ranks of new doctors. Top-down metrics based on “activity” encourage hospitals to spend billions on unnecessary and unwanted treatments towards the end of life. Funding should be relentlessly focused on health outcomes; to encourage innovation, money saved by making people healthier should be made available to regional bodies to reinvest.

NHS衡量和激励绩效的方式也需要改变。目前，该系统是面向输入的。政治家们通常会竞相对新医院的数量或新入职医生的级别做出承诺。基于“活动”的自上而下的指标鼓励医院在生命尽头花费数十亿美元进行不必要和不需要的治疗。资金应坚持不懈地集中在健康结果上；为了鼓励创新，通过提高人们的健康状况而节省的资金应该提供给区域机构进行再投资。

Will any of these changes ever actually happen? The good news is that these ideas are neither new nor even particularly controversial: just this week Sir Keir Starmer, the leader of the Labour Party, laid out in a speech the need to shift focus from acute care to chronic care. The establishment in England of “integrated care systems”, a set of 42 regional partnerships between NHS providers and local bodies, paves the way for a more decentralised approach to health provision. The covid-19 pandemic vividly demonstrated the power of data and technology to reach people quicker, from carefully targeted vaccination campaigns to online consultations.

这些变化真的会发生吗？好消息是，这些想法既不新鲜，也不特别有争议：就在本周，工党领袖基尔·斯塔默爵士（Sir Keir Starmer）在一次演讲中提出了将重点从急性护理转移到慢性护理的必要性。在英格兰建立的“综合护理系统”，即NHS提供者和地方机构之间所建立的42个区域伙伴关系，为更分散的（地方性）保健服务方法铺平了道路。新冠流行生动地展示了数据和技术的力量，可以更快地服务大众，从精心确定的疫苗接种活动到在线咨询。

Faith healing

信仰医治

But this refocusing of effort does require a radical shift in mindset, from politicians above all. Care workers and insulin pumps are less sexy during election campaigns than heart surgeons and new hospitals. No crisis is more urgent for a politician to fix than one involving desperately ill people waiting for ambulances to arrive—one reason why technology and capital budgets are raided to cope with each new winter crisis. The NHS can be saved. But only if the people who run it see their job as keeping Britons healthy at home rather than treating them on the wards. 

但是这种重心转移确实需要从根本上改变思维方式，首先是政治家。在竞选期间，护理人员和胰岛素泵不如心脏外科医生和新建医院那么吸引人。对于政治家来说，没有什么危机比病入膏肓的人等待救护车到达更紧迫的了——这也是为什么技术和资本预算被突击投入以应对每个新的冬季危机的原因之一。要拯救NHS是有可能的。但前提是经营它的人要认识到他们的工作是让英国人在家里保持健康，而不是在病房里治疗他们。