经济学人:国民健康保险制度 遇冷的医改

 　　The NHS

　　国民健康保险制度

　　Health reform in a cold climate

　　遇冷的医改

　　The government's reforms to the NHS are viewed as its biggest failure. They are better than that

　　政府医改被指其最大败笔。“盛名”之下其实难副

　　“WITH the Conservatives there will be no more of the tiresome¹, meddlesome², top-down restructures 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 the Conservative Party cut into Labour's lead on health care, which it had enjoyed almost since it founded the NHS in 1948. The Tories quickly squandered³ their advantage. But their legacy⁴ will be better than they seem to believe.

　　“有了保守党，NHS（National Health Service 英国国民健康保险制度）近十年主要的恼人、好事、专制的医疗结构会一扫而光”，这是英国首相卡梅伦在2009年说过的话，且广受信服。2010年，选民把戴维·卡梅伦选为首相，有部分原因是因为保守党插手了工党主导的医疗保健项目，这个项目几乎自从1948年设立了NHS就赞誉颇多。然而保守党很快就把优势糟蹋一空。但“遗产”比他们大部分人认为的要丰厚。

　　国民健康保险制度.jpg

　　In spite of his promise, Mr Cameron's Conservative-Liberal Democrat⁵ coalition⁶ government embarked⁷ on reforms that would reshape the NHS from the top down. The immense Health and Social Care Act of 2012 increased competition, gave the service greater autonomy and put more decisions about the purchase of care in the hands of local doctors, known inBritainas general practitioners⁸, or GPs. The changes were so big that they could be seen from space, quipped Sir David Nicholson, the departing head of the NHS.

　　即便是承诺在前，卡梅伦领导的保守党和自由民主党联合政府着意的改革仍将自上而下的改造NHS。2012年，声势浩大的医疗社会保障法案使竞争更加激烈，给医疗服务业更大的自主权，以及把决定医疗开销的权利交由本地医生掌握，这类医生在英国被称为全科医生，简称全医。NHS前主管戴维·尼克尔森爵士曾调侃，这么大的变革，在太空都能看到。

　　The government soon came to wish they would disappear. The reforms were never popular with a bemused public. Doctors' groups argued they would lead to a more fragmented and privatised system. Others worried that GPs would be incapable⁹ of commissioning care. Ed Miliband, Labour's leader, dubbed¹⁰ the reforms Mr Cameron's “poll tax”, a reference to the policy that helped fell Margaret Thatcher¹¹. In this case it was Andrew Lansley, the health secretary, who fell. Less than six months after his reforms were passed, Mr Lansley was replaced by Jeremy Hunt, who talks about them as little as possible.

　　很快，政府就希望这些变革能尽快消失。迷惑的民众并不欢迎这些改革。医生群体称，这个权利会让他们最终导致一个更加零碎化、私有化的医疗系统。还有人担心，全科医生并没有能力被委任护理。工党领袖埃德·米利班德把这些改革戏称为卡梅伦的“人头税”，一个曾经让撒切尔夫人下台的参考政策。而现在，下台的是卫生部长安德鲁·兰斯。兰斯的改革通过不到六个月内，他就被杰里米·亨特代替了，而后者几乎对改革只字不谈。

　　The health reforms were supposed to make the NHS more independent. Yet Mr Hunt now styles himself a patients' champion—he is known to ring hospitals to ask about waiting times. This is a concession¹² to reality: politicians will always be held accountable for the performance of the NHS. Still, the frantic¹³ smothering¹⁴ of the reforms conceals¹⁵ something useful. A policy that has caused the government so much embarrassment¹⁶ is quietly bearing fruit.

　　医疗改革旨在让NHS更加独立。然而杰里米·亨特现在自比为病人的胜利，因为大家都知道他常常打电话给医院询问等待时间。这是承认现实：政客永远要为NHS的表现负责。但是，改革密不透风的大动干戈掩盖了一些有用的东西。一个让政府非常窘迫的政策正静悄悄地开花结果。

　　Let 211 flowers bloom

　　让211之花盛开

　　The biggest change was the creation of 211 Clinical Commissioning Groups (CCGs), which placed about 60% of the NHS budget in the hands of local doctors and health workers. They became responsible for procuring¹⁷ hospital care, mental-health services and the like. Navigating¹⁸ a muddled¹⁹ system, the cannier²⁰ ones have figured out ways to realign the incentives²¹ of hospitals, which are often paid per procedure, with those of GPs, who aim to keep people healthy and at home.

　　最大的改变是211临床调试组（CCGs）这一创举，收纳了本地医生和医务人员手中60%的NHS预算。调试组负责采购医院护理、心理健康护理之类的物品。游走在混乱的医疗系统中，头脑灵活的人已经想出办法调整对医院的刺激，这些在每次采购中都会被全科医生偿付，他们旨在使病人保持健康，觉得自在。

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

　　例如英格兰南部贝德福德郡的调试组，已把20余份关于肌肉骨骼保健（面向脆弱的髌骨和股骨骨折之类的治疗）的合同与一份五年期的合同相捆绑，这份合同被商业医疗集团Circle中标。批评家们曾经担心的医疗系统会分崩离析的问题使Circle必须负责，这能使Circle为本地供应商的集成服务负责。病人将会被告知哪个做的最好。Circle及其合伙人必须就后果及分利达成共识。Circle的CFO（首席财政官）保罗·皮耶里希望，这笔交易不仅仅能够改善卫生保健，还能为贝德福德郡留下约3000万英镑（约合5000万美元）的结余。

　　Not all commissioning groups are as bold. But perhaps a quarter are considering contracts like the one in Bedfordshire, reckons Mr Pieri. Diane Bell, a doctor there, says more than 40 CCGs have contacted her group. “Every CCG I look at is doing brave and innovative²² work,” says Shane Gordon, who heads one inEssex.

　　并非所有调试组都能这般大胆无畏。皮耶里推测，约有四分之一的调试组正考虑像贝德福德郡那个一样签订合同。贝德福德郡的一位医生戴安娜·贝尔说，有超过40家临床调试组与她的团队签订了合同。肖恩·戈登在埃塞克斯郡领导一个调试组，他说“每个临床调试组在我看来都在从事勇敢无谓、富于创新的工作”。

　　The Labour Party—which launched a series of NHS reforms during its 13 years in power—says this sort of innovation was on the way anyway, and may have been delayed. Thanks to the giant restructuring of the NHS “we lost two or three years”, says Andy Burnham, the shadow health secretary. He also criticises a regulatory regime that leaves many providers confused. Fair enough. But the reforms replaced bureaucrats²³ with clinicians, which seems to have encouraged creative thinking. Dr Bell was warned by an old hand that outcomes-based contracting would stir up a fight in her group. When she suggested it, though, the other GPs quickly bought in.

　　工党在其执政的13年间，曾颁布了一系列NHS改革，它称这类改革创新不管怎么说都已经在半路上了，还有可能推迟。影子卫生部长安迪·博翰讽刺，幸亏这次NHS巨大的改革让我们“浪费两三年”。他还批评监管制度让许多供应商迷惑不解。虽有道理，但是改革用临床医生代替了官僚分子，似乎还鼓励了创造性思维。贝尔医生曾被这行老手告诫这个以结果为基础的契约签订可能引起团队内讧。尽管当她提到了这个，全科医生还是被迅速引入了。

　　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 integrating health and social care, which currently falls outside the NHS's remit²⁴, would probably shift responsibility to a different local body. Mr Burnham would also clip the wings of reformers by giving NHS providers a built-in advantage in the competition for contracts.

　　下届大选如果工党获胜，米利班德可能搁置临床调试组，正如现在他们才刚刚起航。即使他没有再次重组NHS的计划，他值得赞赏的集成医疗社会保障计划目前还处于NHS的推迟项目，很可能把责任转移到一个不同的地方机构。博翰也会通过给予NHS供应商先天优势的方式，限制改革者在签订合同方面的竞争。

　　But the biggest threat to CCGs and what some of them are doing to improve services is not politics but whether they can move fast enough to keep in front of a funding squeeze, says Thomas Cawston of Reform, a think-tank. Though the NHS has been protected from the worst of austerity, it could fall short by ￡30 billion by 2020—the result of rising demand from a growing elderly population. Sir David warns that without more cash, the service could tip into the red next year.

　　智囊团Thomas Cawston of Reform称，对于临床实验组最大的威胁，以及其中部分改善服务所作的努力不是来自政治方面，而是他们是否可以发展的足够快是实验组一直保持在资金压力前面。尽管NHS被最糟糕的财政紧缩保护，但其资金到2020年还不到300亿英镑，这是不断增长的老龄人口日益增长的需求带来的结果。戴维·尼克尔森爵士警告道，没有更多的钱，这项服务明年就会陷入危机。

　　As money runs short, the real test will arrive. It could be an opportunity for health reformers. Or bureaucrats could panic and revert²⁵ to old ways. Whatever happens, the next government will not be able to duck the issue.

　　随着资金短缺，真正的考验即将来临。这对医改人士而言是一次机遇。那些官僚却可能会陷入恐慌，且想要回归老路。无论发生什么，下届政府都无法回避这一问题。

　　1.seem to 似乎

　　例句:I seem to fritter my time away at coffee mornings.

　　我似乎把时间全都浪费在咖啡早茶会上了。

　　2.lead to 导致；引起；通往

　　例句:Politicians say it could lead to a dissolution of parliament.

　　政客们说这可能会导致议会解散。

　　3.suppose to 认为是…

　　例句:You are not suppose to stay home during the weekend.

　　你不应该周末还呆在家里。

　　4.responsible for 为…负责，是造成…的原因

　　例句:I feel partly responsible for the problems we're in.

　　我觉得应为我们遭遇的问题负部分责任。

1 tiresome   

adj.令人疲劳的，令人厌倦的

参考例句：

• His doubts and hesitations were tiresome.他的疑惑和犹豫令人厌烦。
• He was tiresome in contending for the value of his own labors.他老为他自己劳动的价值而争强斗胜，令人生厌。

2 meddlesome   

adj.爱管闲事的

参考例句：

• By this means the meddlesome woman cast in a bone between the wife and the husband.这爱管闲事的女人就用这种手段挑起他们夫妻这间的不和。
• Get rid of that meddlesome fool!让那个爱管闲事的家伙走开！

3 squandered   

v.（指钱，财产等）浪费，乱花( squander的过去式和过去分词 )

参考例句：

• He squandered all his money on gambling. 他把自己所有的钱都糟蹋在赌博上了。
• She felt as indignant as if her own money had been squandered. 她心里十分生气，好像是她自己的钱给浪费掉了似的。 来自飘（部分）

4 legacy   

n.遗产，遗赠；先人(或过去)留下的东西

参考例句：

• They are the most precious cultural legacy our forefathers left.它们是我们祖先留下来的最宝贵的文化遗产。
• He thinks the legacy is a gift from the Gods.他认为这笔遗产是天赐之物。

5 democrat   

n.民主主义者，民主人士；民主党党员

参考例句：

• The Democrat and the Public criticized each other.民主党人和共和党人互相攻击。
• About two years later,he was defeated by Democrat Jimmy Carter.大约两年后，他被民主党人杰米卡特击败。

6 coalition   

n.结合体，同盟，结合，联合

参考例句：

• The several parties formed a coalition.这几个政党组成了政治联盟。
• Coalition forces take great care to avoid civilian casualties.联盟军队竭尽全力避免造成平民伤亡。

7 embarked   

乘船( embark的过去式和过去分词 )； 装载； 从事

参考例句：

• We stood on the pier and watched as they embarked. 我们站在突码头上目送他们登船。
• She embarked on a discourse about the town's origins. 她开始讲本市的起源。

8 practitioners   

n.习艺者，实习者( practitioner的名词复数 )；从业者（尤指医师）

参考例句：

• one of the greatest practitioners of science fiction 最了不起的科幻小说家之一
• The technique is experimental, but the list of its practitioners is growing. 这种技术是试验性的，但是采用它的人正在增加。 来自辞典例句

9 incapable   

adj.无能力的，不能做某事的

参考例句：

• He would be incapable of committing such a cruel deed.他不会做出这么残忍的事。
• Computers are incapable of creative thought.计算机不会创造性地思维。

10 dubbed   

v.给…起绰号( dub的过去式和过去分词 )；把…称为；配音；复制

参考例句：

• Mathematics was once dubbed the handmaiden of the sciences. 数学曾一度被视为各门科学的基础。
• Is the movie dubbed or does it have subtitles? 这部电影是配音的还是打字幕的？ 来自《简明英汉词典》

11 thatcher   

n.茅屋匠

参考例句：

• Tom Sawyer was in the skiff that bore Judge Thatcher. 汤姆 - 索亚和撒切尔法官同乘一条小艇。 来自英汉文学 - 汤姆历险
• Mrs. Thatcher was almost crazed; and Aunt Polly, also. 撒切尔夫人几乎神经失常，还有波莉姨妈也是。 来自英汉文学 - 汤姆历险

12 concession   

n.让步，妥协；特许(权)

参考例句：

• We can not make heavy concession to the matter.我们在这个问题上不能过于让步。
• That is a great concession.这是很大的让步。

13 frantic   

adj.狂乱的，错乱的，激昂的

参考例句：

• I've had a frantic rush to get my work done.我急急忙忙地赶完工作。
• He made frantic dash for the departing train.他发疯似地冲向正开出的火车。

14 smothering   

（使）窒息， （使）透不过气( smother的现在分词 )； 覆盖； 忍住； 抑制

参考例句：

• He laughed triumphantly, and silenced her by manly smothering. 他胜利地微笑着，以男人咄咄逼人的气势使她哑口无言。
• He wrapped the coat around her head, smothering the flames. 他用上衣包住她的头，熄灭了火。

15 conceals   

v.隐藏，隐瞒，遮住( conceal的第三人称单数 )

参考例句：

• He conceals his worries behind a mask of nonchalance. 他装作若无其事，借以掩饰内心的不安。 来自《简明英汉词典》
• Drunkenness reveals what soberness conceals. 酒醉吐真言。 来自《简明英汉词典》

16 embarrassment   

n.尴尬；使人为难的人(事物)；障碍；窘迫

参考例句：

• She could have died away with embarrassment.她窘迫得要死。
• Coughing at a concert can be a real embarrassment.在音乐会上咳嗽真会使人难堪。

17 procuring   

v.（努力）取得， （设法）获得( procure的现在分词 )；拉皮条

参考例句：

• He was accused of procuring women for his business associates. 他被指控为其生意合伙人招妓。 来自辞典例句
• She had particular pleasure, in procuring him the proper invitation. 她特别高兴为他争得这份体面的邀请。 来自辞典例句

18 navigating   

v.给（船舶、飞机等）引航，导航( navigate的现在分词 )；（从海上、空中等）横越；横渡；飞跃

参考例句：

• These can also be very useful when navigating time-based documents, such as video and audio. 它对于和时间有关的文档非常有用，比如视频和音频文档。 来自About Face 3交互设计精髓
• Vehicles slowed to a crawl on city roads, navigating slushy snow. 汽车在市区路上行驶缓慢，穿越泥泞的雪地。 来自互联网

19 muddled   

adj.混乱的；糊涂的；头脑昏昏然的v.弄乱，弄糟( muddle的过去式)；使糊涂；对付，混日子

参考例句：

• He gets muddled when the teacher starts shouting. 老师一喊叫他就心烦意乱。
• I got muddled up and took the wrong turning. 我稀里糊涂地拐错了弯。 来自《简明英汉词典》

20 cannier   

精明的，狡猾的( canny的比较级 )

参考例句：

• We should carry out the policy of integrating unified planning with the principle of adaptation to local conditions. 我们应该执行计划同因事制宜的原则相结合的政策。
• Talks will now begin about integrating the activities of both companies. 关于合并两家公司业务的谈判现在将会开始。

21 incentives   

激励某人做某事的事物( incentive的名词复数 )； 刺激； 诱因； 动机

参考例句：

• tax incentives to encourage savings 鼓励储蓄的税收措施
• Furthermore, subsidies provide incentives only for investments in equipment. 更有甚者，提供津贴仅是为鼓励增添设备的投资。 来自英汉非文学 - 环境法 - 环境法

22 innovative   

adj.革新的，新颖的，富有革新精神的

参考例句：

• Discover an innovative way of marketing.发现一个创新的营销方式。
• He was one of the most creative and innovative engineers of his generation.他是他那代人当中最富创造性与革新精神的工程师之一。

23 bureaucrats   

n.官僚( bureaucrat的名词复数 )；官僚主义；官僚主义者；官僚语言

参考例句：

• That is the fate of the bureaucrats, not the inspiration of statesmen. 那是官僚主义者的命运，而不是政治家的灵感。 来自辞典例句
• Big business and dozens of anonymous bureaucrats have as much power as Japan's top elected leaders. 大企业和许多不知名的官僚同日本选举出来的最高层领导者们的权力一样大。 来自辞典例句

24 remit   

v.汇款，汇寄；豁免（债务），免除（处罚等）

参考例句：

• I hope you'll remit me the money in time.我希望你能及时把钱汇寄给我。
• Many immigrants regularly remit money to their families.许多移民定期给他们的家人汇款。

25 revert   

v.恢复，复归，回到

参考例句：

• Let us revert to the earlier part of the chapter.让我们回到本章的前面部分。
• Shall we revert to the matter we talked about yesterday?我们接着昨天谈过的问题谈，好吗？