英国医疗服务体系生了什么“病”？ | 经济学人社论

Leaders | The sick factor

社论 | 论“病” 

Leaders | The sick factor

社论 | 论“病” 

How to fix the NHS

如何改革英国国家医疗服务体系

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

资金会派上用场，但更重要的是转移重心

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.

比起君主立宪制，英国人认为他们的医疗体系更值得骄傲。今年7月，英国国家医疗服务体系（NHS）即将迎来“七十五岁大寿”，但气氛却并不热烈。英格兰地区的待诊积压人数已飙升至700多万，许多人看病要等几个月，甚至几年。约30万名成人等着做社保评估。250万人因病失业，创历史新高。同时，NHS却呈现离职潮。比起其他富裕国家，英国的基本健康指标十分糟糕。比起10年前，英国人的寿命几乎没有延长，罹患癌症等疾病的病人存活率在世界范围垫底。疫情期间，英国民众对NHS的表现大为赞赏，然而现如今，他们却失望至极，束手无策。

注释：

social-care assessment: a social-care assessment is an evaluation conducted by local authorities in the UK to determine an individual's eligibility for social care services, such as home care, residential care, or day care. The assessment takes into account the individual's physical, mental, and emotional needs, as well as their ability to carry out daily activities on their own. Based on the assessment, the local authority may provide social care services or offer advice on other forms of support available to the individual.

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.

出现问题时，大刀阔斧的改革往往是最吸引人的。一部分人想要彻底改革NHS的资金模式，向德国法国学习，由税收支付转变成以社保基金支付。其他人则提出要增大资金补助。NHS曾被前财政大臣尼格尔·劳森（Nigel Lawson）称为“民族宗教”，英国人不会轻易放弃目前由税收支付、全民免费的模式。此外，英国近来推行的变革性措施反响平平，人们对改革NHS也信心不足。

注释：

Free at the point of use: The NHS in the UK is funded through general taxation, and is free at the point of use. This means that UK residents can access healthcare services without paying upfront fees or charges. However, some services such as dental care and prescription medicines may require patients to pay a fee.

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.

这么做也没必要。NHS的改革要大胆，但并不复杂：目前NHS忙于“救治”，却忽略了名字中的“健康”，而现在就需要将重心拨回来。此举意味着花更多的钱，但如果要把钱花在刀刃上，那就需要将重点从医院转向社区，从治疗转向预防，从一味输血转向优化产出。

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.

政府最大的开支项就是健康。花在公共服务上的每一镑里，就有38便士花在了NHS上。但英国医疗保健支出的GDP占比却低于德法国等国。英国尤为吝啬资本支出：在经合组织成员国中英国人均资本支出最低。但是人们对医疗服务的需求只会越来越多。在未来25年里，85岁及以上的英国人数将增加一倍。NHS是欧洲最大的单一雇主；而"成本病"则意味着医护人员的工资要不断增长，才能与劳动力市场上的其他雇主竞争。

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。当前，这个问题的答案可以归结为一个词：医院。按实际价值计算，过去十年的公共卫生（不包括新冠肺炎预防）和社会关怀服务的支出有所下降。甚至在新冠疫情之前，NHS总支出中用于基层和社区医疗的比例就在下降，而分配给医院的比例已上升至近三分之二。从富裕国家医疗支出GDP占比和强制医疗保险支出占比来看，只有美国在医院上的支出超过了英国。

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.

这样的投入毫无意义。以医院为重点的医疗系统只会在人们得病之后才提供服务。这就好比把烟雾报警器拆掉再购置更多的灭火器（一样本末倒置）。现在大部分医疗和社会护理支出都用于治疗糖尿病、高血压、关节炎等慢性病。这些病症最好是由病人在全科医生和当地专家的共同帮助下，居家自主调理。用于基础保健的资金份额应从目前NHS预算的8%恢复至20年前的11%。社会护理也需要更多的资金并制定合理的长期投资计划。

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.

让护理走出医院走进社区，就是要注重疾病预防：让人们尽可能长久地保持健康。这意味着拓宽医疗保健服务的范围。尽管疾病治疗更能吸引注意力，但它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。肥胖就是一个明显的例子。英国肥胖率排欧洲第三。一个肥胖病人的治疗费用是非肥胖病人的两倍。为防止医院候诊室和住院部挤满肥胖病人，政府需要更有力的策略来解决肥胖问题，例如有效利用疗效显著的新型抗肥胖药物。

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考核与激励绩效的方式同样需要改变。当前，该系统以投入为导向。政客们通常竞相承诺建设更多的医院或招聘更多的医生。这种自上而下的指标体系建立在医院的“活跃度”上，使得它们在不必要的临终治疗上花费了数十亿镑。我们应坚持以健康结果为导向使用资金；通过改善人民健康状况所节约的治疗费用，应该允许地方机构用其再投资，以鼓励创新。

注释：

ranks [ plural ]：the members of a group or organization （参见Cambridge Dictionary）

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.

这些改变真的会发生吗？好消息是，这些想法比较成熟，也没有特别大的争议：就在本周，工党党魁基尔·斯塔默爵士（Sir Keir Starmer）在演讲中指出：我们需要将重心从紧急救治转向长期照护。英格兰建立的联合医疗系统(integrated care systems, ICSs)是由42个地区的地方机构和NHS联手打造，这一系统为实现去中心化的卫生健康服务奠定了基础。新冠疫情生动地展示了数据和技术的力量，从有针对性的疫苗接种到在线问诊，都能更快地触达人群。

Faith healing

信仰疗法

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.

转变重心需要转变思维，尤其是政客们的思维。在竞选活动中，护理人员和胰岛素泵不如心外科医生和新医院那样有吸引力。对于政客而言，没有什么危机比救治那些等待救护车的重病患者更紧急——这也是科技和资本预算被挪用于应对新寒冬危机的原因之一。NHS还有救。前提是管理者能够意识到，他们的职责是保障英国人民可以健健康康待在家里，而不是在病房里治病。

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