2015年经济学人 国民健康保险制度 遇冷的医改（在线收听）

The NHS

Health reform in a cold climate

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

“WITH the Conservatives there will be no more of the tiresome,

meddlesome, 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 squandered their advantage.

But their legacy will be better than they seem to believe.

In spite of his promise, Mr Cameron's Conservative-Liberal Democrat coalition government embarked 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 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.

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 incapable of commissioning care.

Ed Miliband, Labour's leader, dubbed the reforms Mr Cameron's “poll tax”, a reference to the policy that helped fell Margaret Thatcher.

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.

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 concession to reality: politicians will always be held accountable for the performance of the NHS.

Still, the frantic smothering of the reforms conceals something useful.

A policy that has caused the government so much embarrassment is quietly bearing fruit.

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 procuring hospital care, mental-health services and the like.

Navigating a muddled system, the cannier ones have figured out ways to realign the incentives of hospitals,

which are often paid per procedure, with those of GPs, who aim to keep people healthy and at home.

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).

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 innovative work,” says Shane Gordon, who heads one inEssex.

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 bureaucrats 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.

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 remit, 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.

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.

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 government will not be able to duck the issue.