( # 後記 NYT)
The Lancet, Volume 377, Issue 9763, Page 353, 29 January 2011
doi:10.1016/S0140-6736(11)60110-4Cite or Link Using DOI
The end of our National Health Service
There is a crisis in the National Health Service (NHS). The publication of the Health and Social Care Bill last week heralds dramatic changes for the NHS, which will affect the way public health and social care are provided in the UK. Those changes alone will have huge impact, but it is the formation of an NHS Commissioning Board, and commissioning consortia, that will once and for all remove the word “national” from the health service in England. The result, due to come into force in 2013, will be the catastrophic break up of the NHS.
Maintaining the status quo in the NHS is not an option. The NHS is not delivering the care that patients need. Patients with cancer, for example, are less likely to survive in the UK than in Australia, Canada, Sweden, or Norway. Michel Coleman and colleagues' Lancet Article, published last month, reports that the survival of patients with primary colorectal, lung, breast, or ovarian cancer is lower in the UK than in other countries with similar wealth, universal access to health care, and good cancer registration data. Survival is, they argue, “the key index of the overall effectiveness of health services in the management of patients with cancer”.
Despite the huge sums of money pumped into the NHS over the past few years―particularly into the salary budget for staff―translation into benefits for patients is hard to identify. Moreover, the unyielding mountain of bureaucracy that is integral to the NHS stifles innovation, such that it is difficult to design the services needed for local populations.
Will the changes outlined in the Health and Social Care Bill solve these problems within the NHS and improve care for patients? The truth is that we do not know. What we do know is that putting general practitioners (GPs) in charge of commissioning health services for their patients is similar, in some respects, to the fundholding experiment in the 1990s. The principle then was that GPs controlled the budgets to buy the specialist care their patients needed. Fundholding took years to implement, but evidence on short-term or long-term benefits for patients is lacking. In the current Bill, health outcomes, including prevention of premature death, will be the responsibility of the NHS Commissioning Board, which has been asked to publish a business plan and annual reports on progress. That business plan is urgently needed to allow transparent appraisal of how the Board plans to monitor patients' outcomes.
The UK coalition Government has now been in power for about 8 months. Neither the Conservatives nor the Liberal Democrats included the formation of an NHS Commissioning Board, or GPs' commissioning consortia, in their health manifestos on which the electorate voted. The speed of the introduction of the Health and Social Care Bill is surprising, especially given the absence of relevant detail in the health manifestos. The Conservatives promised, if elected, to scrap “politically motivated targets that have no clinical justification” and called themselves the “party of the NHS”―a commitment that seems particularly hollow now.
Since its establishment in July, 1948, the aim of the NHS has been to offer a comprehensive service to improve health and prevent illness, available to all in England and Wales (and then extended throughout the UK), which is largely free of charge. Health care for all, for free, has been the common ethos and philosophy throughout the NHS. On July 3, 1948, in an editorial entitled “Our Service”, The Lancet commented: “Now that everyone is entitled to full medical care, the doctor can provide that care without thinking of his own profit or his patient's loss, and can allocate his efforts more according to medical priority. The money barrier has of course protected him against people who do not really require help, but it has also separated him from people who really do.” Now, GPs will return to the market place and will decide what care they can afford to provide for their patients, and who will be the provider. The emphasis will move from clinical need (GPs' forte) back to cost (not what GPs were trained to evaluate). The ethos will become that of the individual providers, and will differ accordingly throughout England, replacing the philosophy of a genuinely national health service.
Health professionals cannot say that no change is needed―it most certainly is. But there is sufficient uncertainty and concern about the changes outlined in the Health and Social Care Bill to pause, to learn from the past, and to consider what the changes mean for patients' outcomes. As it stands, the UK Government's new Bill spells the end of the NHS.
Cameron Seeks Vast Changes in England’s Health Service
By SARAH LYALL
Published: January 19, 2011
LONDON ― Prime Minister David Cameron on Wednesday proposed a radical reorganization of England’s health care system, introducing legislation that would hand responsibility for most of the country’s health budget to its 42,000 general practitioners and, his political opponents say, open the door to private competition that could threaten the foundations of socialized care.
Mr. Cameron argues that the bill, said to be the biggest overhaul of the National Health Service since it was founded in 1948, is essential to increase efficiency and allow doctors, patients and localities more control of how the health budget is spent.
Yet the prime minister, who promised during last year’s election campaign that he had no radical plans to change the health service, faces formidable opposition from a wide array of critics. These include the British Medical Association, members of Mr. Cameron’s own Conservative Party, patient advocates, health care specialists, health workers’ unions and even many of the primary care doctors who are supposed to benefit under the proposals.
“We feel, and many others feel, that this reform is too much, too complicated and not necessary in terms of organizational change,” Dr. Clare Gerada, chairwoman of the Royal College of General Practitioners, said in an interview. “Nobody’s been able to convince anyone I’ve spoken to why we’re doing it.”
The complaints include criticisms that the plan is ill thought out, that it will prove too costly at a time of budgetary retrenchment and that the competition and choice it promises will cause confusion and duplication, and encourage decision-making based on cost rather than quality. In the eyes of conspiracy-minded Labour politicians, however, the bill is a stalking horse for the eventual privatization of health care.
“My concern, in the long run, is that this is opening up the whole of the N.H.S., all areas, to competition and private health companies,” John Healey, the Labour health spokesman, told The Daily Telegraph.
The bill would allow general practitioners to commission services from “any willing provider,” which the government says would encourage efficiency and quality, as providers competed for business.
But the N.H.S. Confederation, which represents organizations in the health service, says this will lead to the closing of some hospitals and a move toward a more disjointed system in which private companies pick up the slack. Already there are signs that American companies are stepping in to provide consulting and commissioning services.
“Forcing commissioners of care to tender contracts to any willing provider, including N.H.S. providers, voluntary sector organizations and commercial companies, could destabilize local health economies and fragment care for patients,” Hamish Meldrum, chairman of the British Medical Association Council ― the group’s executive committee ― said in a statement.
Other critics said the changes would simply not deliver the results Mr. Cameron promised. “The real choice is not between stability and change, but between reforms that are well executed and deliver results for patients, and reforms that are poorly planned and risk undermining the N.H.S.,” Chris Ham, chief executive of the King’s Fund, an independent research group focusing on health care, said in a statement.
But Mr. Cameron is committed to making “fundamental” changes. “I don’t think there is an option of just quietly standing still, staying where we are and putting a bit more money into the N.H.S.,” he told BBC Radio this week.
Under the government’s plan, some $127 billion a year ― about 80 percent of the total health care budget ― would be handed directly to the country’s 42,000 general practitioners, who would join together into consortia that would negotiate to buy treatment from hospitals and specialists. The 151 bodies that currently make such spending decisions, known as primary care trusts, would be abolished, as would another layer of bureaucracy, 10 regional groups known as Strategic Health Authorities.
In order to help take politics out of the system, the government says, the N.H.S. would be administered by a new, independent body, known as the N.H.S. Commissioning Board.
The changes apply only to England; other parts of Britain have separate systems. Despite the opposition to the proposals, the government’s parliamentary majority means that the bill is likely to pass, possibly in altered form after it has made its way through the legislative process.
The government argues that the plan will cut waste, allow patients more autonomy over their treatment and give doctors and localities, rather than bureaucrats, more direct control of the system. Like other health care systems around the world, the N.H.S., which provides treatment free at the point of service, has struggled to keep up with rising costs and increased demand.
The government points out that doctors across nearly half of England have already formed consortia. Dr. Ken Aswani, who works in Waltham Forest outside London, told the BBC: “We will be looking to build on what we have been doing in recent years. That means getting services out of hospitals and into the community where they are more accessible.”
Dr. Michael Dixon, chairman of the N.H.S. Alliance, which supports clinicians’ ability to commission health care, said it was inevitable that the proposals would provoke opposition.
“Giving power to frontline clinicians and their patients is bound to upset those with vested interests, such as some of the more centralist senior N.H.S. managers who are used to ruling the roost,” Dr. Dixon said.
But opposition has been gathering since Mr. Cameron gave notice of his intentions last summer. One issue, Dr. Gerada said, is that the reorganization ― which was included in the small print of the governing coalition’s election manifestos, but not raised in the campaign ― seems like another in a wearying series of changes.
In the 1990s, John Major’s Conservative government gave general practitioners the option of being “fundholders,” letting them buy treatment for their patients. About half of England’s general practitioners joined the program, which was scrapped when Labour took power in 1997. Labour then introduced the Strategic Health Authorities, which the government seeks to abandon.
“We’ve had so many top-down reorganizations in this health service,” Dr. Gerada said. “It’s like planting a plant, pulling it up every few years, looking at its roots and then putting it back into the earth ― instead of plucking out the weeds and trimming back the overgrowth while letting the garden flourish.”
Other critics say the proposals are too expensive, particularly when the health service is being deprived of the huge spending increases it received under 13 years of Labour government. Despite pledges to preserve the health budget from the severe cuts affecting most departments, the government is still demanding that the N.H.S. make $32 billion in efficiency savings by 2014.
The government estimates that 20,900 N.H.S. workers, mostly from the primary care trusts, are expected to lose their jobs, The Guardian reported, though some would probably be rehired by general practitioner groups.
One of the plan’s boldest components is the pledge that patients will now get to choose their doctors, their hospitals and their treatments ― a radical proposal for a service in which patients can now sometimes wait months for specialist care.
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