評論
打印
Britain
英國
Reforming the NHS
改革國民醫保系統
Bitter medicine
良藥苦口
Competition is not the cause of the NHS's problems
競爭不是導致國民醫保系統問題的原因
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.
正如病人害怕打針一樣，許多醫生害怕政客推進以市場為導向的健康政策。20多年來，歷屆政府向英格蘭公費醫療系統注入了一些競爭因素。聯邦政府于2012年通過的改革措施則加速了近期的競爭力度，令許多人感到惶恐不安。
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”.
英國首相戴維·卡梅倫曾希望能夠看到所有的醫保合同通過競標獲利。最后，卡梅倫發布的新政策承認非競爭性的醫保合同有時也是最好的選擇，前提是這一過程透明、公正、惠及病人。但是當地負責購買保險的團體（又稱作臨床調試組或CCGs）抱怨他們收到的信息雜亂不堪。有些運行CCGs的醫生說如果不對醫保合同進行競標，他們擔心會受到醫務人員的控訴。2月份，影子衛生部長安迪·伯納姆表示，去年CCGs在競標律師身上花費了500萬英鎊（840萬美元）。前英國國民保健系統的首腦大衛·尼克松說，該系統“深陷競爭法的沼澤”。
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.
衛生監管部門，Monitor，心照不宣地承認這些規則可以更明確。教導人們了解CCGs的真實意思非常費事。前國民醫保系統的合作與競爭委員會首腦，安德魯·泰勒表示如果他們尊敬常識、將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可能誤以為聯邦政府最近的改革意味著其決議將在法院受到更多的挑戰。事實上，醫務人員多年來變得越來越好斗。2011年，倫敦的英國皇家布魯頓學院提起起訴，希望能夠取消一項在其他醫院鞏固兒科心臟手術的計劃（泰勒說，起訴失敗，但是引起了“信號傳遞效應”）。事實上，通過加強Monitor的角色的重要性，政府改革為解決法庭外的爭端提供了方法。
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.
改革可能對醫院合并產生更大的影響。政府清楚地表明：競爭法令——禁止反競爭合同和濫用市場壟斷地位——應用于國民醫保系統。10月份，多賽特的兩所債務深重的醫院被禁止合并，因為病人的選擇范圍太小。這充滿了爭議，因為醫院辯解說他們的合并將帶來更好的治療條件，而這是很難衡量的。有些人懷疑競爭權威部門可能有成本效益分析權。
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的大衛·班尼特相信悲觀主義者對結束當前的競爭政權更感興趣，而并非改善情況。勃漢姆承認，即使工黨贏得了下一屆選舉，他的選擇也跟現在一樣受限。他建議支持的NHS系統下簽合同的醫院和診所可能在歐洲法案下是違法的。
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.
國民醫保系統的新老大，西門·斯蒂文斯似乎非常熱衷于競爭。如果他能讓評論家確信其優點，病人也能從中獲益。關于英國醫院的兩項研究表明，競爭同樣可以拯救生命而不會提高成本。另一研究表明，離競爭對手近的家庭醫生表現更好。藥物有效，是適合下一劑猛料了。譯者：毛慧 校對：邵夏沁
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