The national health service (nhs) in England is under unprecedented strain. So it is baffling that more than one in ten of its beds are occupied by patients who do not need them. Some 13,600 inpatients are medically ready to be discharged yet remain in hospital—more than double the number five years ago. This is bad for them. It is even worse for the sick people waiting outside in ambulances, queuing in record numbers to get in.

英國國家醫(yī)療服務(wù)體系正面臨著前所未有的壓力。因此，醫(yī)院超過十分之一的床位被不需要的病人占用，這令人費(fèi)解。大約有13600名住院病人已經(jīng)做好了出院的準(zhǔn)備，但他們?nèi)栽卺t(yī)院里，這一數(shù)字是五年前的兩倍多。這對(duì)他們不利。更糟糕的是，病人在外面的救護(hù)車上等待，排隊(duì)的人數(shù)創(chuàng)下了記錄。

Discharging a patient requires a dizzying amount of administrative work, much of it still done on paper. “It is easier to track a pizza than it is our patients across health and social care,” says John O’Connell, who is leading an nhs pilot scheme to digitise the process. One problem, however, cannot be solved by technology. Increasingly, when elderly patients are ready to leave, there are no carers to look after them.

讓病人出院需要大量的行政工作，其中許多工作仍需在紙上完成。正在領(lǐng)導(dǎo)著NHS數(shù)字化試點(diǎn)計(jì)劃的約翰?奧康納表示:“追蹤披薩比追蹤醫(yī)療和社會(huì)保健領(lǐng)域的患者更容易?！?然而，有一個(gè)問題是技術(shù)無法解決的。越來越多的老年病人準(zhǔn)備離開時(shí)，卻沒有護(hù)理人員照顧他們。

In 2021 the number of workers in adult social care fell by 50,000, the first decline in the decade that there have been records. There are 165,000 vacancies; one in 11 posts is unfilled. As the workforce dwindles, so does the quantity and quality of care on offer. The proportion of older people receiving state-supported long-term care is decreasing, but this does not seem to be because their needs are diminishing. Public satisfaction with social care fell from 29% three years ago to a dismal 15% in 2021.

2021年，成人社會(huì)關(guān)懷工作人員的數(shù)量減少了5萬人，這是有記錄以來的十年來的首次下降?，F(xiàn)在有16.5萬個(gè)職位空缺; 每11個(gè)職位中就有一個(gè)空缺。隨著勞動(dòng)力的減少，提供的醫(yī)療服務(wù)的數(shù)量和質(zhì)量也在下降。接受國家支持的長(zhǎng)期護(hù)理的老年人比例正在下降，但這似乎并不是因?yàn)樗麄兊男枨笤跍p少。公眾對(duì)社會(huì)關(guān)懷的滿意度從三年前的29%下降到2021年的慘淡的15%。

Frustration stems in part from a complicated system. Long-term social care, consisting of both in-home care and care in nursing and residential homes, is supplied by thousands of mostly private providers. It is difficult to get publicly funded care. In order to qualify, a person must typically be deemed by their local authority to have both high needs and assets of less than ￡23,250 ($28,100). Separate funding streams hobble efforts to integrate the nhs and the social-care system: money for social care is still primarily funnelled to local authorities through the Department for Levelling Up, Housing and Communities, not the Department of Health.

不滿意部分源于一個(gè)復(fù)雜的體系。長(zhǎng)期的社會(huì)關(guān)懷（包括家庭護(hù)理和養(yǎng)老院護(hù)理）是由數(shù)千個(gè)提供者提供，其中大部分都是私人提供。很難得到公共資助的醫(yī)療服務(wù)。為了符合資格，一個(gè)人通常必須被當(dāng)?shù)卣J(rèn)為有很高的需求，并且資產(chǎn)不超過23250英鎊(28100美元)。獨(dú)立的資金來源阻礙了NHS和社會(huì)關(guān)懷體系的整合: 社會(huì)關(guān)懷的資金主要還是通過“住房、社區(qū)及振興地方”部門(而不是衛(wèi)生部)流向地方政府。

More fundamentally, in the decade from 2010 the funding of local authorities fell by half in real terms. Some losses were made up by rises in local council tax and by the introduction of a special social-care “precept”, or levy. But in 2020-21 prices, social-care spending still dropped from ￡514 per adult citizen in 2010-11 to ￡478 per adult ten years later.

更為根本的是，從2010年開始的10年里，地方政府的實(shí)際資金減少了一半。一些損失是靠增加地方市政稅和引入一項(xiàng)特別的社會(huì)關(guān)懷“規(guī)定”或稅收來彌補(bǔ)的。但在2020-2021年的物價(jià)水平上，社會(huì)關(guān)懷支出仍然從2010-2011年的每位成年公民514英鎊下降到10年后的每位成年人478英鎊。

Josh Hawker of AbleCare Homes, which runs six care homes in the south-west, says his firm needs ￡800-1,000 per week to look after a client. That seems cheap given that it costs the nhs at least ￡2,500 per week to keep someone in hospital. But Mr Hawker says that Bristol city council pays ￡771 for each state-funded client, almost irrespective of their needs. The “council just aren’t paying what it costs to look after people”, he says. Self-funders, who make up the remaining third of residents, end up paying more to subsidise others.

AbleCare Homes的約翰·霍克在西南部經(jīng)營著六家養(yǎng)老院，他說他的公司每周需要800-1000英鎊來照顧一個(gè)客戶?？紤]到NHS每周至少要花費(fèi)2500英鎊讓一個(gè)人住院，這看起來很便宜。但是霍克先生說，布里斯托市議會(huì)為每個(gè)政府資助的客戶支付771英鎊，幾乎不去考慮他們的需求。他說:“ 議會(huì)根本沒有支付照顧人們所需的費(fèi)用。” 剩下的三分之一居民得自籌資金，他們最終會(huì)為補(bǔ)貼他人支付更多的錢。

The miserliness exerts downward pressure on wages. In March the median hourly wage of a care worker was ￡9.50, less than that for an easier job stacking supermarket shelves. One of Mr Hawker’s employees had been an “excellent” care worker for a decade. But when she quit for an entry-level job as an administrator in the nhs, she instantly received a pay bump of 30%. Some providers fill gaps with pricey agency workers. Others make do with fewer staff.

這種吝嗇給工資帶來了下行壓力。三月份，護(hù)工的時(shí)薪中值是9.5英鎊，比一份更輕松的在超市擺貨物上架工作的時(shí)薪還低。霍克先生的一名雇員是一名“優(yōu)秀”的護(hù)工，工作了十年。但當(dāng)她辭去NHS的初級(jí)管理工作時(shí)，她立即獲得了30%的加薪。一些提供人用昂貴的專門機(jī)構(gòu)人員填補(bǔ)空缺。其他公司則用更少的員工將就。

The losers are among society’s most vulnerable. Age uk, a charity, estimates that around 2.6m adults who need care are not receiving it. In the first quarter of 2022, 2.2m hours of home care could not be delivered because of staff shortages. Providers such as Right at Home, a home-care franchise, are focusing more on self-funding clients. “It means we can pay our workers more,” says Lucy Campbell, the ceo.

吃虧的還是社會(huì)上最弱勢(shì)的群體。慈善機(jī)構(gòu)Age uk估計(jì)，大約260萬需要照顧的成年人沒有得到照顧。在2022年第一季度，由于人手短缺，220萬小時(shí)的家庭護(hù)理無法交付。像仁愛華這樣的家庭護(hù)理特許經(jīng)營企業(yè)的服務(wù)提供者更關(guān)注于自籌資金的客戶。公司首席執(zhí)行官露西?坎貝爾說，“這意味著我們可以給員工支付更多的工資?！?/p>

Care homes must contend with soaring energy costs, too. That means making tough choices. At best, carpets grow shabbier and walls aren’t repainted. At worst, clients with more complex (ie, costlier) needs are turned away. Profit margins are at their lowest since the Care Quality Commission, a regulator, began monitoring them in 2015. “You’d be mad to open a care home at the moment,” says Mr Hawker.

養(yǎng)老院也必須應(yīng)對(duì)不斷飆升的能源成本。這意味著要做出艱難的選擇。最好的情況下，地毯會(huì)變得破舊不堪，墻壁也不會(huì)重新粉刷。在最壞的情況下，有更復(fù)雜(即更昂貴)需求的客戶會(huì)被拒之門外。利潤(rùn)率處于自2015年監(jiān)管機(jī)構(gòu)護(hù)理質(zhì)量委員會(huì)開始監(jiān)控以來的最低水平?；艨讼壬f:“在這個(gè)時(shí)候開養(yǎng)老院，你一定是瘋了。”

The autumn statement did bring some relief. Jeremy Hunt, the chancellor of the exchequer, pledged up to ￡7.5bn of extra money for social care over two years, a chunk of which will come from allowing local authorities to raise council tax. Around a third of the money is tied to hospital discharges, to be split with the nhs; some of the rest will probably go on wages.

秋季的聲明確實(shí)帶來了一些寬慰。英國財(cái)政大臣杰里米?亨特承諾在未來兩年內(nèi)為社會(huì)關(guān)懷投入至多75億英鎊的額外資金，其中很大一部分資金將來自允許地方政府提高市政稅。大約三分之一的資金用于醫(yī)院出院，與NHS分?jǐn)? 剩下的部分可能會(huì)變成工資。

Mr Hunt described the cash as “the biggest increase [in social-care funding] under any government of any colour in history”. But the money fell short of his own assessment of what was needed when he chaired the health and social-care select committee: in December 2021 he said that social care needed an extra ￡7bn a year.

亨特先生稱這筆現(xiàn)金是“歷史上任何黨派政府(在社會(huì)關(guān)懷基金上)最大的增加”。但這筆錢沒有達(dá)到他在擔(dān)任衛(wèi)生和社會(huì)關(guān)懷特別委員會(huì)主席時(shí)對(duì)所需資金的評(píng)估: 2021年12月，他說社會(huì)關(guān)懷每年需要額外的70億英鎊。

“These are tiny sums of money given the issues,” says Geoff Butcher, who runs Blackadder care homes in the West Midlands. “I honestly cannot see them addressing the problem.” Clive Lewis, the leader of Wokingham council, in the south-east, agrees. To save money for social care, he is still considering reducing the bin collection from weekly to fortnightly. He is already relocating council employees in order to rent out the top two floors of their offices.

在西米德蘭茲郡經(jīng)營黑蛇養(yǎng)老院的杰夫·波奇說:“ 考慮到這些問題，這些錢是很少的。說實(shí)話，我看不出他們?cè)诮鉀Q這個(gè)問題?！睎|南部沃金厄姆議會(huì)領(lǐng)袖克萊夫?劉易斯對(duì)此表示贊同。為了給社會(huì)關(guān)懷省點(diǎn)錢，他還在考慮把收垃圾的時(shí)間從每周減少到兩周。他已經(jīng)在重新安置議會(huì)雇員，以便出租他們辦公室的頂層兩層。

Some of the extra cash has been found by deferring a plan to cap the lifetime costs of personal care paid by individuals in England at ￡86,000. Councils say that the cap could never have been implemented by October 2023, as originally scheduled. Others (including the plan’s architect, Sir Andrew Dilnot) feel that delay is short-sighted: the introduction of a cap would bring peace of mind to many. Around one in seven over-65s face bills of more than ￡100,000 for their own care. The government is plugging holes in social care but “the public wants more than that,” says Simon Bottery of The King’s Fund, a think-tank. “They want a better, fairer system.”

一些額外的現(xiàn)金是通過推遲實(shí)施一項(xiàng)計(jì)劃來獲得的，該計(jì)劃將英國個(gè)人終身護(hù)理費(fèi)用限制在8.6萬英鎊。地方議會(huì)表示，按照原計(jì)劃，2023年10月之前不可能實(shí)施這一限制。其他人(包括該計(jì)劃的設(shè)計(jì)者安德魯·迪爾洛特爵士)認(rèn)為拖延是短視的: 引入上限會(huì)給許多人帶來安心。在65歲以上的人群中，大約有七分之一的人需要支付超過10萬英鎊的醫(yī)療費(fèi)用。政府正在填補(bǔ)社會(huì)關(guān)懷的漏洞，但“公眾想要的不止這些，” 智庫國王基金的西蒙·博特里說道。“他們想要一個(gè)更好、更公平的體系?！?/p>