经济学人下载:改革国民医保系统 良药苦口

Britain

英国

Reforming the NHS

改革国民医保系统

Bitter medicine
良药苦口

Competition is not the cause of the NHS's problems
竞争不是导致国民医保系统问题的原因

LIKE patients shrinking from needles, many doctors fear politicians pushing market-oriented health policies. For more than two decades governments of all shades have injected small doses of competition into England's publicly funded health system. Reforms passed by the coalition government in 2012 provided the most recent jab. They have left many people feeling queasy.
正如病人害怕打针一样，许多医生害怕政客推进以市场为导向的健康政策。20多年来，历届政府向英格兰公费医疗系统注入了一些竞争因素。联邦政府于2012年通过的改革措施则加速了近期的竞争力度，令许多人感到惶恐不安。

David Cameron, the prime minister, had hoped to see nearly all of the NHS's contracts awarded through competitive bidding. In the end, his new rules acknowledged that non-competitive contracting is sometimes the best choice if the process is transparent, unbiased, and clearly benefits patients. But the local groups responsible for purchasing care (known as Clinical Commissioning Groups, or CCGs) complain that they have received mixed messages. Some of the doctors that run CCGs say they fear legal challenges from health providers if they do not tender all of their contracts competitively. In February Andy Burnham, the shadow health secretary, said CCGs had spent 5m ($8.4m) on competition lawyers during the previous year. Sir David Nicholson, former head of the NHS, said that the service is “bogged down in a morass of competition law”.
英国首相戴维·卡梅伦曾希望能够看到所有的医保合同通过竞标获利。最后，卡梅伦发布的新政策承认非竞争性的医保合同有时也是最好的选择，前提是这一过程透明、公正、惠及病人。但是当地负责购买保险的团体（又称作临床调试组或CCGs）抱怨他们收到的信息杂乱不堪。有些运行CCGs的医生说如果不对医保合同进行竞标，他们担心会受到医务人员的控诉。2月份，影子卫生部长安迪·伯纳姆表示，去年CCGs在竞标律师身上花费了500万英镑（840万美元）。前英国国民保健系统的首脑大卫·尼克松说，该系统“深陷竞争法的沼泽”。

The health regulator, Monitor, tacitly concedes that the rules could be clearer. It is busy tutoring CCGs on what they actually mean. If they honour common sense and put patients' interests first “they're 95% there”, says Andrew Taylor, former head of the NHS's Co-operation and Competition panel.
卫生监管部门，Monitor，心照不宣地承认这些规则可以更明确。教导人们了解CCGs的真实意思非常费事。前国民医保系统的合作与竞争委员会首脑，安德鲁·泰勒表示如果他们尊敬常识、将病人的利益放在第一位，“病人利益至上，占95%”。

And CCGs are probably wrong to believe that the coalition's most recent reforms will mean their decisions get challenged more often through the courts. In truth, health providers have been growing more combative for years. In 2011 the Royal Brompton hospital in London went to court in the hope of reversing a plan to consolidate paediatric heart surgery in other hospitals. (It lost, but the case had a “signalling effect”, says Mr Taylor.) In fact by beefing up Monitor's role, the government's reforms have provided a means of resolving disputes outside the courts.
CCGs可能误以为联邦政府最近的改革意味着其决议将在法院受到更多的挑战。事实上，医务人员多年来变得越来越好斗。2011年，伦敦的英国皇家布鲁顿学院提起起诉，希望能够取消一项在其他医院巩固儿科心脏手术的计划（泰勒说，起诉失败，但是引起了“信号传递效应”）。事实上，通过加强Monitor的角色的重要性，政府改革为解决法庭外的争端提供了方法。

The reforms will probably have a bigger effect on hospital mergers. The government made it clear that the Competition Act—which prohibits anti-competitive agreements and the abuse of a dominant market position—should be applied to the NHS. In October two cash-strapped hospitals in Dorset were blocked from joining up on the grounds that it would give patients too few choices. This was controversial because the hospitals argued that their agreement would result in better care, a difficult thing to gauge. Some doubt the competition authorities can get the cost-benefit analysis right.
改革可能对医院合并产生更大的影响。政府清楚地表明：竞争法令——禁止反竞争合同和滥用市场垄断地位——应用于国民医保系统。10月份，多赛特的两所债务深重的医院被禁止合并，因为病人的选择范围太小。这充满了争议，因为医院辩解说他们的合并将带来更好的治疗条件，而这是很难衡量的。有些人怀疑竞争权威部门可能有成本效益分析权。

David Bennett of Monitor believes some of the hand-wringers are more interested in ending, not improving, the current competition regime. Mr Burnham admits as much, but his options are limited even if Labour wins the next election. His proposal to favour NHS hospitals and clinics for contracts may turn out to be illegal under European law.
Monitor的大卫·班尼特相信悲观主义者对结束当前的竞争政权更感兴趣，而并非改善情况。勃汉姆承认，即使工党赢得了下一届选举，他的选择也跟现在一样受限。他建议支持的NHS系统下签合同的医院和诊所可能在欧洲法案下是违法的。

The NHS's new boss, Simon Stevens, seems keen on competition. Patients will benefit if he can convince critics of its merits. Two studies at English hospitals found that competition saved lives without increasing costs. Another study showed that family doctors located close to rival practices performed better. The medicine is working. Time to increase the dosage.
国民医保系统的新老大，西门·斯蒂文斯似乎非常热衷于竞争。如果他能让评论家确信其优点，病人也能从中获益。关于英国医院的两项研究表明，竞争同样可以拯救生命而不会提高成本。另一研究表明，离竞争对手近的家庭医生表现更好。药物有效，是适合下一剂猛料了。