2015年经济学人 改革国民医保系统 良药苦口

（单词翻译）

Britain

Reforming the NHS

Bitter medicine

Competition is not the cause of the NHS's problems

LIKE patients shrinking from needles, many doctors fear politicians pushing market-oriented health policies.

For more than two decades governments of all shades have injected small doses of competition into England's publicly funded health system.

Reforms passed by the coalition¹ government in 2012 provided the most recent jab. They have left many people feeling queasy².

David Cameron, the prime minister, had hoped to see nearly all of the NHS's contracts awarded through competitive bidding.

In the end, his new rules acknowledged that non-competitive contracting is sometimes the best choice if the process is transparent³, unbiased, and clearly benefits patients.

But the local groups responsible for purchasing care (known as Clinical Commissioning Groups, or CCGs)

complain that they have received mixed messages. Some of the doctors that run CCGs say they fear legal challenges from health providers if they do not tender all of their contracts competitively.

In February Andy Burnham, the shadow health secretary, said CCGs had spent 5m ($8.4m) on competition lawyers during the previous year.

Sir David Nicholson, former head of the NHS, said that the service is “bogged down in a morass⁴ of competition law”.

The health regulator, Monitor, tacitly concedes that the rules could be clearer.

It is busy tutoring CCGs on what they actually mean.

If they honour common sense and put patients' interests first “they're 95% there”,

says Andrew Taylor, former head of the NHS's Co-operation and Competition panel.

And CCGs are probably wrong to believe that the coalition's most recent reforms will mean their decisions get challenged more often through the courts.

In truth, health providers have been growing more combative⁵ for years.

In 2011 the Royal Brompton hospital in London went to court in the hope of reversing a plan to consolidate⁶ paediatric heart surgery in other hospitals.

(It lost, but the case had a “signalling effect”, says Mr Taylor.)

In fact by beefing up Monitor's role, the government's reforms have provided a means of resolving disputes outside the courts.

The reforms will probably have a bigger effect on hospital mergers⁷.

The government made it clear that the Competition Act—which prohibits anti-competitive agreements and the abuse of a dominant⁸ market position—should be applied⁹ to the NHS.

In October two cash-strapped hospitals in Dorset were blocked from joining up on the grounds that it would give patients too few choices.

This was controversial because the hospitals argued that their agreement would result in better care, a difficult thing to gauge¹⁰.

Some doubt the competition authorities can get the cost-benefit analysis right.

David Bennett of Monitor believes some of the hand-wringers are more interested in ending, not improving, the current competition regime.

Mr Burnham admits as much, but his options are limited even if Labour wins the next election.

His proposal to favour NHS hospitals and clinics for contracts may turn out to be illegal under European law.

The NHS's new boss, Simon Stevens, seems keen on competition. Patients will benefit if he can convince critics of its merits.

Two studies at English hospitals found that competition saved lives without increasing costs.

Another study showed that family doctors located close to rival practices performed better. The medicine is working. Time to increase the dosage.