A New Plan to Ready the National Health Service for an Ageing Society

一项旨在让国民医疗服务体系为老龄化社会做好准备的新计划

Every Wednesday morning a motley group of health and social-care professionals, ranging from a geriatrician to a district nurse to a social worker, get together for a virtual ward meeting in Alderney hospital. The goal is to get to the bottom of the problems facing the ward’s patients, who, were it not for the new system, would be in an actual, physical ward, but are instead being treated at home. Does the 85-year-old with a urinary-tract infection just need some antibiotics? Or does he also need someone to come round to fix his heating and check on his wife with dementia? Angie Terry, a community matron, jokes that at times the detective-style hunt for causes becomes like the American crime drama, CSI – only here the goal is to keep people out of a state institution.

每周三上午，一群形形色色的医疗和社会照护专业人士——从老年病医生到社区护理人员再到社工——齐聚奥尔德尼医院（Alderney hospital）参加虚拟病房会议。他们的目标是弄明白病房中的病人面临的问题。如果没有这个新体系，这些病人就得住在现实的病房里，但现在他们可以在家接受治疗。那位尿路感染的85岁老人是不是只给开些抗生素就可以了？还是说还得有人上门给他修修暖气，看看他那个患痴呆症的老伴的情况？社区护工安吉·特里（Angie Terry）开玩笑说，有时候，这种侦探般寻根究底的过程就像美国刑侦剧《犯罪现场调查》（CSI）的剧情一样，只不过这么做的目的是让人们不进公立医院。

Alderney, in Dorset, provides a glimpse of what officials hope the National Health Service will look like in ten years’ time. On January 7th Theresa May and Simon Stevens, the head of nhs England, set out a plan for the next decade. This followed Mrs May’s promise last summer that the health service would receive £20.5bn ($26bn) more per year by 2023-24 – a welcome rise but still less than economists think the service needs to get back to pre-austerity standards. Having already been promised the cash, NHS England was told to work out how to spend it.

从位于多塞特郡（Dorset）的奥尔德尼可以一窥官员们对于英国国民医疗服务体系（National Health Service，简称NHS）在十年后的愿景。1月7日，特雷莎·梅和英格兰NHS 负责人西蒙·史蒂文斯（Simon Stevens）制定了一项十年计划。此前，特雷莎·梅在去年夏天承诺，到2023 年至2024 年，这一医疗服务体系每年将额外获得205亿英镑（合260亿美元）的经费。这样的增长是可喜的，但在经济学家看来仍不足以让该体系恢复到紧缩前的标准。既已获得拨款承诺，英格兰NHS需按要求制定出将如何花这些钱。

Its plans include headline-grabbing measures like expanding child mental-health provision, doing more consultations by video-link and catching more cancers early. But the priority is dealing with an ageing society. The aim is to save money by preventing illness and keeping people out of hospital. To do this, spending will focus on primary and community services, creating new multidisciplinary teams of doctors and social services. Success, the plan suggests, will come only if the NHS is radically reshaped.

其计划包括一些吸引眼球的措施，比如扩大儿童心理健康服务、开展更多视频会诊，以及尽早发现更多癌症病患。但当务之急是应对一个老龄化社会。计划的目标是通过预防疾病和避免人们进医院来节省经费。因此，支出将集中在初级和社区服务上，建立由医生和社会福利部门组成的多学科新团队。该计划表明，只有彻底改革NHS才能成功。

Change of prescription

更改处方

The idea at the heart of the plan is to roll back competition in favour of co-operation. Since the early 1990s the parts of the nhs that pay for services (typically gps, or family doctors) have been separated from those that provide them (hospitals, for example), in the hope that an “internal market” will drive up standards. Reforms by the Tory-Lib Dem coalition in 2012 sought to expand this system. But experiments in recent years have seen the NHS move in the opposite direction. As Nigel Edwards of the Nuffield Trust, a think-tank, notes, the long-term plan represents a new stage in the “political falling out of love with the use of market-based mechanisms”.

该计划的核心思想是从竞争转向合作。自上世纪90年代初以来，NHS中为服务付费的部分（通常是全科医生或家庭医生）已经与提供服务的部分（例如医院）分离，希望通过“内部市场”来提高标准。2012年保守党和自由民主党联合政府的改革试图扩大这一体系。但近年来的实验表明，NHS正朝着相反的方向发展。正如智库Nuffield Trust的奈杰尔·爱德华兹（Nigel Edwards）所指出的，这个长期计划代表了一个“政治上不再喜欢利用市场机制”的新阶段。

By 2021 England will be divided into what are known as integrated care systems (ICSs). Already introduced in 14 parts of the country, which range in size from 530,000 to 2.7m people, these bring together payers and providers to collectively plan services and manage resources. In time they will be given more control over spending and held to account for the overall health of their population. The hope is that this will encourage collaboration between different parts of the nhs, and between the NHS and local government.

到2021年，英格兰将采用所谓的整合医疗系统（integrated care systems，ICS），分区管理。ICS已在英格兰14个地区推出，这些地区的人口从53万至270万不等。这一系统将支付方和服务提供方集合在一起，共同规划服务、管理资源。未来系统还将逐步获得更大的支出控制权，也会对所管辖人口的整体健康负责。新系统的设计者希望这将鼓励NHS的不同部门之间以及NHS和地方政府之间的合作。

What this means in practice varies according to an area’s needs. “A lot of it is about putting people in the same room and letting them work it out for themselves,” explains Tim Goodson, head of Dorset’s ICS. In Poole a new team has begun work not just on keeping people out of hospital, but on getting them out once they are in. Having got to know many repeat visitors, they offer advice to accident and emergency wards on whether admission is really necessary. After a person has been in hospital for a few days the team begins to assess whether hospitalisation is in the patient’s interest. Often it is not.

具体的实施方法因各地区的需求而异。“很大一部分工作是把大家都聚在一起，让他们自己解决问题。”多塞特ICS的负责人蒂姆·古德森（Tim Goodson）解释说。在普尔（Poole），一个新的团队已经开始运作，不仅要让人们远离医院，还要让已在住院的人能尽快出院。在知道有许多反复就诊的人之后，团队还就是否确实有必要让他们入院向急诊病房提供建议。一个人住院几天后，团队就开始评估住院是否符合该患者的利益。很多情况下并不需要住院。

Bringing about this re-organisation of the health service without any new legislation can be tricky. Local NHS officials have had to fight against existing payment mechanisms and legal frameworks to make the icss work. Mr Stevens thus hopes Parliament will pass legislation to change the rules to fit the system he is already introducing. Indeed, the NHS’s long-term plan ends, ever so humbly, with a “provisional list of potential legislative changes for Parliament’s consideration” that would, among other things, loosen current procurement rules.

在没有任何新立法的情况下对医疗服务启动这样的重组可能会很棘手。为了让ICS系统运作起来，地方NHS官员不得不对抗现有的支付机制和法律框架。因此，史蒂文斯希望议会能够通过立法修改规则，以适应他已经在推行的体系。事实上，NHS这份长期计划的结尾以极其谦恭的语气写道，“附上可能的立法变更的暂定列表，供议会考虑”，其中包括放宽现行的采购规定。

Even with those legal changes, success is far from guaranteed. There is evidence that integrating services can cut costs and improve outcomes. Some worry, however, that icss may turn into local monopolies, responding to the central diktats rather than the needs of local populations. NHS officials argue, in effect, that the efficiencies enabled by integration should outweigh those lost by reduced competition, and that competition will be strengthened in areas where it shows most success, like in patients choosing where to have elective surgery. But Andrew Haldenby of Reform, a think-tank, says that progress in most existing icss has been slow. Change is rarely brought about by “bureaucratic exhortation”, he notes.

即使有了这些法律变更，成功也远非十拿九稳。有证据表明整合服务可以降低成本并改善结果。但有人担心ICS可能会变成地方垄断机构，只响应中央指令而不顾当地居民的需要。实际上，NHS官员辩称，整合带来的高效应该会超过竞争减少造成的低效，而在竞争带来最大成功的领域，如病人选择在哪里进行非紧急的择期手术，竞争会被加强。但是智库Reform的安德鲁·豪登比（Andrew Haldenby）说，现有的ICS大多数都进展缓慢。他指出，“打官腔的劝勉”很少能带来变革。

The reforms face strong headwinds. One is staff shortages. The NHS has 100,000 vacancies. As Richard Murray of the King’s Fund, another think-tank, points out, having more money is no good if there are no staff to spend it on. Another is the mess in social care. Age Concern, a charity, estimates that 1.4m people do not get the care they need, and the health service often has to deal with the consequences. The NHS is the largest employer in Europe and an enormously complex organisation. Reform is difficult at the best of times. And these are hardly the best of times.

改革面临强大的阻力。其一是人员短缺。NHS有10万个职位空缺。正如另一家智库国王基金（King’s Fund）的理查德·默里（Richard Murray）所指出的那样，如果没人来领薪水，那NHS有再多资金也无益。另一个是社会照护服务的混乱。一家名为“老人关怀”（Age Concern）的慈善机构估计，有140万人得不到他们所需的社会照护，由此造成的后果常常得由医疗机构去应对。NHS是欧洲最大的雇主，也是一个极其复杂的机构。即使是在最好的光景，改革也是困难的，何况现在不是。

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