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“WITH the Conservatives there will be no more of the tiresome, meddlesome, top-downrestructures 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 theConservative Party cut into Labour's lead on health care, which it had enjoyed almost since itfounded the NHS in 1948. The Tories quickly squandered their advantage. But their legacy willbe better than they seem to believe.

“有了保守黨，NHS(National Health Service 英國國民健康保險(xiǎn)制度)近十年主要的惱人、好事、專制的醫(yī)療結(jié)構(gòu)會(huì)一掃而光”，這是英國首相卡梅倫在2009年說過的話，且廣受信服。2010年，選民把戴維·卡梅倫選為首相，有部分原因是因?yàn)楸Ｊ攸h插手了工黨主導(dǎo)的醫(yī)療保健項(xiàng)目，這個(gè)項(xiàng)目幾乎自從1948年設(shè)立了NHS就贊譽(yù)頗多。然而保守黨很快就把優(yōu)勢糟蹋一空。但“遺產(chǎn)”比他們大部分人認(rèn)為的要豐厚。

In spite of his promise, Mr Cameron's Conservative-Liberal Democrat coalition governmentembarked on reforms that would reshape the NHS from the top down. The immense Healthand Social Care Act of 2012 increased competition, gave the service greater autonomy andput more decisions about the purchase of care in the hands of local doctors, known inBritainasgeneral 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.

即便是承諾在前，卡梅倫領(lǐng)導(dǎo)的保守黨和自由民主黨聯(lián)合政府著意的改革仍將自上而下的改造NHS。2012年，聲勢浩大的醫(yī)療社會(huì)保障法案使競爭更加激烈，給醫(yī)療服務(wù)業(yè)更大的自主權(quán)，以及把決定醫(yī)療開銷的權(quán)利交由本地醫(yī)生掌握，這類醫(yī)生在英國被稱為全科醫(yī)生，簡稱全醫(yī)。NHS前主管戴維·尼克爾森爵士曾調(diào)侃，這么大的變革，在太空都能看到。

The government soon came to wish they would disappear. The reforms were never popularwith a bemused public. Doctors' groups argued they would lead to a more fragmented andprivatised system. Others worried that GPs would be incapable of commissioning care. EdMiliband, Labour's leader, dubbed the reforms Mr Cameron's “poll tax”, a reference to thepolicy that helped fell Margaret Thatcher. In this case it was Andrew Lansley, the healthsecretary, who fell. Less than six months after his reforms were passed, Mr Lansley wasreplaced by Jeremy Hunt, who talks about them as little as possible.

很快，政府就希望這些變革能盡快消失。迷惑的民眾并不歡迎這些改革。醫(yī)生群體稱，這個(gè)權(quán)利會(huì)讓他們最終導(dǎo)致一個(gè)更加零碎化、私有化的醫(yī)療系統(tǒng)。還有人擔(dān)心，全科醫(yī)生并沒有能力被委任護(hù)理。工黨領(lǐng)袖埃德·米利班德把這些改革戲稱為卡梅倫的“人頭稅”，一個(gè)曾經(jīng)讓撒切爾夫人下臺(tái)的參考政策。而現(xiàn)在，下臺(tái)的是衛(wèi)生部長安德魯·蘭斯。蘭斯的改革通過不到六個(gè)月內(nèi)，他就被杰里米·亨特代替了，而后者幾乎對(duì)改革只字不談。

The health reforms were supposed to make the NHS more independent. Yet Mr Hunt nowstyles 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 performanceof the NHS. Still, the frantic smothering of the reforms conceals something useful. A policy thathas caused the government so much embarrassment is quietly bearing fruit.

醫(yī)療改革旨在讓NHS更加獨(dú)立。然而杰里米·亨特現(xiàn)在自比為病人的勝利，因?yàn)榇蠹叶贾�道他常常打電話給醫(yī)院詢問等待時(shí)間。這是承認(rèn)現(xiàn)實(shí)：政客永遠(yuǎn)要為NHS的表現(xiàn)負(fù)責(zé)。但是，改革密不透風(fēng)的大動(dòng)干戈掩蓋了一些有用的東西。一個(gè)讓政府非常窘迫的政策正靜悄悄地開花結(jié)果。

Let 211 flowers bloom

讓211之花盛開

The biggest change was the creation of 211 Clinical Commissioning Groups (CCGs), whichplaced about 60% of the NHS budget in the hands of local doctors and health workers. Theybecame responsible for procuring hospital care, mental-health services and the like. Navigatinga muddled system, the cannier ones have figured out ways to realign the incentives ofhospitals, which are often paid per procedure, with those of GPs, who aim to keep peoplehealthy and at home.

最大的改變是211臨床調(diào)試組(CCGs)這一創(chuàng)舉，收納了本地醫(yī)生和醫(yī)務(wù)人員手中60%的NHS預(yù)算。調(diào)試組負(fù)責(zé)采購醫(yī)院護(hù)理、心理健康護(hù)理之類的物品。游走在混亂的醫(yī)療系統(tǒng)中，頭腦靈活的人已經(jīng)想出辦法調(diào)整對(duì)醫(yī)院的刺激，這些在每次采購中都會(huì)被全科醫(yī)生償付，他們旨在使病人保持健康，覺得自在。

The commissioning group in Bedfordshire, for example, has bundled some 20 contracts formusculoskeletal care (treatment for things like weak knees and cracked hips) into one five-yearcontract that was won by Circle, a commercial health group. Far from fragmenting thesystem, as critics had feared, this has made Circle responsible for integrating the services oflocal providers. Patients will be told which are doing best. Circle and its partners must achievean 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).

例如英格蘭南部貝德福德郡的調(diào)試組，已把20余份關(guān)于肌肉骨骼保健(面向脆弱的髕骨和股骨骨折之類的治療)的合同與一份五年期的合同相捆綁，這份合同被商業(yè)醫(yī)療集團(tuán)Circle中標(biāo)。批評(píng)家們曾經(jīng)擔(dān)心的醫(yī)療系統(tǒng)會(huì)分崩離析的問題使Circle必須負(fù)責(zé)，這能使Circle為本地供應(yīng)商的集成服務(wù)負(fù)責(zé)。病人將會(huì)被告知哪個(gè)做的最好。Circle及其合伙人必須就后果及分利達(dá)成共識(shí)。Circle的CFO(首席財(cái)政官)保羅·皮耶里希望，這筆交易不僅僅能夠改善衛(wèi)生保健，還能為貝德福德郡留下約3000萬英鎊(約合5000萬美元)的結(jié)余。

Not all commissioning groups are as bold. But perhaps a quarter are considering contracts likethe one in Bedfordshire, reckons Mr Pieri. Diane Bell, a doctor there, says more than 40 CCGshave contacted her group. “Every CCG I look at is doing brave and innovative work,” saysShane Gordon, who heads one inEssex.

并非所有調(diào)試組都能這般大膽無畏。皮耶里推測，約有四分之一的調(diào)試組正考慮像貝德福德郡那個(gè)一樣簽訂合同。貝德福德郡的一位醫(yī)生戴安娜·貝爾說，有超過40家臨床調(diào)試組與她的團(tuán)隊(duì)簽訂了合同。肖恩·戈登在埃塞克斯郡領(lǐng)導(dǎo)一個(gè)調(diào)試組，他說“每個(gè)臨床調(diào)試組在我看來都在從事勇敢無謂、富于創(chuàng)新的工作”。

The Labour Party—which launched a series of NHS reforms during its 13 years in power—saysthis sort of innovation was on the way anyway, and may have been delayed. Thanks to thegiant restructuring of the NHS “we lost two or three years”, says Andy Burnham, the shadowhealth secretary. He also criticises a regulatory regime that leaves many providers confused.Fair enough. But the reforms replaced bureaucrats with clinicians, which seems to haveencouraged creative thinking. Dr Bell was warned by an old hand that outcomes-basedcontracting would stir up a fight in her group. When she suggested it, though, the other GPsquickly bought in.

工黨在其執(zhí)政的13年間，曾頒布了一系列NHS改革，它稱這類改革創(chuàng)新不管怎么說都已經(jīng)在半路上了，還有可能推遲。影子衛(wèi)生部長安迪·博翰諷刺，幸虧這次NHS巨大的改革讓我們“浪費(fèi)兩三年”。他還批評(píng)監(jiān)管制度讓許多供應(yīng)商迷惑不解。雖有道理，但是改革用臨床醫(yī)生代替了官僚分子，似乎還鼓勵(lì)了創(chuàng)造性思維。貝爾醫(yī)生曾被這行老手告誡這個(gè)以結(jié)果為基礎(chǔ)的契約簽訂可能引起團(tuán)隊(duì)內(nèi)訌。盡管當(dāng)她提到了這個(gè)，全科醫(yī)生還是被迅速引入了。

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 integratinghealth and social care, which currently falls outside the NHS's remit, would probably shiftresponsibility to a different local body. Mr Burnham would also clip the wings of reformers bygiving NHS providers a built-in advantage in the competition for contracts.

下屆大選如果工黨獲勝，米利班德可能擱置臨床調(diào)試組，正如現(xiàn)在他們才剛剛起航。即使他沒有再次重組NHS的計(jì)劃，他值得贊賞的集成醫(yī)療社會(huì)保障計(jì)劃目前還處于NHS的推遲項(xiàng)目，很可能把責(zé)任轉(zhuǎn)移到一個(gè)不同的地方機(jī)構(gòu)。博翰也會(huì)通過給予NHS供應(yīng)商先天優(yōu)勢的方式，限制改革者在簽訂合同方面的競爭。

But the biggest threat to CCGs and what some of them are doing to improve services is notpolitics but whether they can move fast enough to keep in front of a funding squeeze, saysThomas Cawston of Reform, a think-tank. Though the NHS has been protected from the worstof austerity, it could fall short by ￡30 billion by 2020—the result of rising demand from agrowing elderly population. Sir David warns that without more cash, the service could tip intothe red next year.

智囊團(tuán)Thomas Cawston of Reform稱，對(duì)于臨床實(shí)驗(yàn)組最大的威脅，以及其中部分改善服務(wù)所作的努力不是來自政治方面，而是他們是否可以發(fā)展的足夠快是實(shí)驗(yàn)組一直保持在資金壓力前面。盡管NHS被最糟糕的財(cái)政緊縮保護(hù)，但其資金到2020年還不到300億英鎊，這是不斷增長的老齡人口日益增長的需求帶來的結(jié)果。戴維·尼克爾森爵士警告道，沒有更多的錢，這項(xiàng)服務(wù)明年就會(huì)陷入危機(jī)。

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 governmentwill not be able to duck the issue.

隨著資金短缺，真正的考驗(yàn)即將來臨。這對(duì)醫(yī)改人士而言是一次機(jī)遇。那些官僚卻可能會(huì)陷入恐慌，且想要回歸老路。無論發(fā)生什么，下屆政府都無法回避這一問題。