Britons used to see the National Health Service (nhs) as a source of pride. It is now a source of danger. Leaked data suggest that, in one week in December, over 50,000 sick people in England waited more than 12 hours to be admitted to hospital from accident-and-emergency (a&e) departments. The Economist’s mortality model echoes the warnings from emergency doctors: around one in four excess deaths in recent months is attributable to delays in emergency care.

英國(guó)人過去將國(guó)民醫(yī)療服務(wù)體系(NHS)視為一種驕傲?，F(xiàn)在它是一個(gè)危險(xiǎn)的來源。泄露的數(shù)據(jù)顯示，在去年12月的一周內(nèi)，英國(guó)有超過5萬名病人在急診室等待了超過12個(gè)小時(shí)才被醫(yī)院收治。《經(jīng)濟(jì)學(xué)人》的死亡率模型與急診醫(yī)生的警告相呼應(yīng): 近幾個(gè)月來，大約四分之一的額外死亡是由于急診護(hù)理的延誤造成的。

The scenes in a&e are just the most alarming symptoms of a health-care system that is failing. Downstream, one in seven patients is ready to leave the wards, which would free up beds for those clamouring to get in, but they would have no one to look after them if they were released from hospital. The government’s proposed solution—an extra ￡200m ($243m) to block-book places in private care homes—seems sensible. But it will take more than that to deal with the deeper problem: a chronic shortage of staff.

急診室的場(chǎng)景只是一個(gè)正在失效的醫(yī)療保健系統(tǒng)最令人擔(dān)憂的癥狀。其下游，七分之一的病人準(zhǔn)備離開病房，這將為那些吵著要進(jìn)來的人騰出床位，但如果他們出院了，就沒有人照顧他們了。政府提出的解決方案似乎是明智的，即額外支付2億英鎊(2.43億美元)批量預(yù)定私人養(yǎng)老院的名額。但要解決更深層次的問題:，即長(zhǎng)期的人員短缺問題，這一解決方案還不夠。

Upstream, the same issue bedevils general practice, the network of family doctors where many of the pressures on the nhs first build. General practitioners (gps) are conventionally a patient’s first and most frequent point of contact with Britain’s health-care professionals. But the system is buckling. Demand is rising—owing partly to a backlog in cases from the pandemic and partly to an increase in patients with complex, chronic diseases. And the number of doctors is dwindling, as gps retire early, emigrate or reduce their hours. There are 15% more junior doctors in hospitals than there were in 2019, but 2% fewer full-time family doctors (albeit more practice staff). As a result, millions are not getting the care they need. Many turn directly to the hospitals. Polling shows that one in five people who cannot see their family doctor goes to a&e instead. Many simply get sicker.

在上游，同樣的問題困擾著全科診療（家庭醫(yī)生系統(tǒng)是國(guó)民醫(yī)療服務(wù)體系最先承受壓力的地方）。一般來說，全科醫(yī)生通常是患者與英國(guó)醫(yī)療保健專業(yè)人員的第一個(gè)也是最頻繁的接觸點(diǎn)。但是這個(gè)系統(tǒng)正在垮掉。需求正在增加，部分原因是大流行病例積壓，部分原因是患有復(fù)雜慢性病的患者增加。由于全科醫(yī)生提前退休、移民或縮短工作時(shí)間，醫(yī)生的數(shù)量正在減少。與2019年相比，醫(yī)院的初級(jí)醫(yī)生增加了15%，但全職家庭醫(yī)生減少了2%(盡管執(zhí)業(yè)人員增加了)。結(jié)果，數(shù)以百萬計(jì)的人得不到他們所需的醫(yī)療服務(wù)。許多人直接求助于醫(yī)院。民意調(diào)查顯示，五分之一不能看家庭醫(yī)生的人會(huì)去急診室。許多人則是病情加重。

To slow the stampede of older gps retiring early, the government should exempt doctors from pension-tax rules that penalise high-earners. More advanced technology, including automated telephone services and online consultations, would calm the 8am panic to book an appointment.

為了減緩老年全科醫(yī)生提前退休的蜂擁現(xiàn)象，政府應(yīng)該免除醫(yī)生的養(yǎng)老金稅規(guī)定，因?yàn)檫@些規(guī)定對(duì)高收入者不利。更先進(jìn)的技術(shù)，包括自動(dòng)電話服務(wù)和在線咨詢，將緩解早上8點(diǎn)預(yù)約的恐慌。

More profound changes are needed to make this foundation of the nhs sturdy again. General practices are businesses, most commonly owned by gp partners. The building will collapse if partners continue to quit. One option is to make all gps salaried nhs employees, as consultants are in hospitals. The Labour Party is considering this approach, along with other reforms such as allowing self-referrals to certain specialists.

需要進(jìn)行更深刻的改革，才能使NHS的根基再次穩(wěn)固起來。全科醫(yī)生是企業(yè)，通常由全科醫(yī)生合伙人擁有。如果合伙人持續(xù)退出，公司就會(huì)倒閉。一種選擇是讓所有全科醫(yī)生都成為領(lǐng)薪的NHS雇員，就像醫(yī)院的咨詢師一樣。工黨正在考慮這種方法，以及其他改革，如允許自行轉(zhuǎn)診到某些專家。

Buying out gp partners and their premises would be costly. It would also be risky to jettison a model that, for all its faults, remains the envy of other countries. Primary care provides most of the nhs’s patient contacts for just 9% of its budget. Specialists, meanwhile, have seen their hospital waiting lists spiral to over 7m: self-referrals would make the problem worse.

收購(gòu)全科醫(yī)生合伙人及其經(jīng)營(yíng)場(chǎng)所的成本很高。拋棄一個(gè)盡管存在種種缺陷，但仍令其他國(guó)家羨慕不已的模式也是有風(fēng)險(xiǎn)的。初級(jí)保健能夠?yàn)镹HS大部分的病人提供服務(wù)，且僅占其9%的預(yù)算。與此同時(shí)，專家們發(fā)現(xiàn)他們的醫(yī)院候診名單已經(jīng)上升到700多萬人: 自行轉(zhuǎn)診將使問題變得更糟。

It would be better to make changes from within. The nhs should abolish the Quality and Outcomes Framework, a pointless pay-for-performance scheme which means that gps spend hours filling out forms instead of seeing patients. Pharmacies and other parts of the primary-care system should be encouraged to do more. Practices specialising in chronic illnesses should receive higher fixed fees per patient, enabling continuity of care for those who most need it. Reweighting funding to benefit clinics in the poorest areas would reduce health disparities: they care for 10% more patients than practices in the richest areas, but receive 7% less cash.

從內(nèi)部做出改變會(huì)更好。NHS應(yīng)該廢除“質(zhì)量與產(chǎn)出框架”，這是一項(xiàng)毫無意義的績(jī)效薪酬計(jì)劃，這意味著全科醫(yī)生要花幾個(gè)小時(shí)在填寫表格上，而不是去看病人。應(yīng)該鼓勵(lì)藥房和初級(jí)保健系統(tǒng)的其他部分做更多的工作。專門治療慢性疾病的診所應(yīng)該從每個(gè)病人身上收取更高的固定費(fèi)用，從而為那些最需要的人提供持續(xù)的治療。對(duì)資金進(jìn)行重新調(diào)整，從而使最貧困地區(qū)的診所受益，將減少健康差距: 他們比最富裕地區(qū)的診所多照顧10%的病人，但他們獲得的現(xiàn)金卻比他們少7%。

The nhs’s most urgent problem lies in its hospitals. But the health service will not be fixed unless general practice is, too.

NHS最緊迫的問題在于它的醫(yī)院。但是，除非全科醫(yī)生問題解決了，否則醫(yī)療服務(wù)問題不會(huì)解決。