How Health Care Works Around the World

In a doctor’s waiting room in South London sit three people of varying ages and ethnicities1ethnicity種族。, waiting among a sea of empty green plastic chairs.

It’s Tuesday afternoon in the Hetherington Group Practice2practice（醫(yī)生、律師的）工作地點(diǎn)。, which serves more than 8,500 people from dozens of miles in every direction from its base in the bustling3bustling繁忙的。area of Brixton4位于倫敦南部，屬于蘭貝斯（Lambeth）區(qū)。20世紀(jì)初，這里是倫敦主要購(gòu)物中心之一，以時(shí)髦和富庶而聞名。經(jīng)歷了二戰(zhàn)后加勒比海移民帶來(lái)的動(dòng)蕩，如今已成為一個(gè)多元文化區(qū)。.

[2] Adorning5adorn裝飾。the many notice boards on the walls are posters asking people to get flu vaccinations6vaccination疫苗接種。, to embrace more walking as part of their day to day7day to day日常。and to speak up if they feel that they may have symptoms of bowel8bowel腸。cancer.

Another poster informs that the Accident and Emergency room at the local hospital “won’t kiss it better,” appealing to people not to visit their local ER when something is not urgent.倫

敦南部的一間候診室內(nèi)坐著三個(gè)人，他們年齡有別，種族各異，身邊空著一大片綠色的塑料候診椅子。

這是某個(gè)星期二的下午，地點(diǎn)是布里克斯頓鬧市區(qū)的赫瑟林頓集團(tuán)診所。這家診所為方圓幾十英里的8500多位居民提供醫(yī)療服務(wù)。

[2]診所的墻上有許多布告板，上面貼著各種海報(bào)：有的讓人們接種流感疫苗；有的建議人們每天多走路；有的提醒人們一旦感覺(jué)有疑似腸癌的癥狀，要立即看醫(yī)生。

還有一張海報(bào)告知人們當(dāng)?shù)蒯t(yī)院的急診室“并非人到病除”，呼吁大家不是緊急情況就不要去急診室。

[3] In the corner of the waiting room sits a “patient pod9pod分離艙。” consisting of a computer, a blood pressure machine and scale, for people to measure their vitals10vitals=vital signs生命體征。in their own time.

“It’s about managing demand,” said Dr.Steve Mowle, one of the nine physicians at the practice and a spokesman for the Royal College of General Practitioners11英國(guó)皇家全科醫(yī)學(xué)院，成立于1952年，致力于維持全科醫(yī)療服務(wù)的最高標(biāo)準(zhǔn)。.

[4] Demand on the practice has increased significantly in recent years.Unusually, the rise is not in terms of patient numbers, which have in fact fallen,but by people living longer with greater numbers of increasingly complex conditions to manage. Each day, Mowle will have contact with 40 to 50 patients, he explained, with 60% of those in person and the rest through phone consultations.

“My clinics are longer,” Mowle said.A clinic represents a half-day of seeing patients and is meant to last three hours each. His clinics routinely last at least fi ve hours.

[5] The demographic12demographic同類客戶群體。of his patient base is as vast as the region the practice covers, ranging from the homeless,newly arrived refugees and blue-collar workers to high-earning middle-class and lawyers and bankers whose houses are worth millions. More than 140 languages are spoken locally.

[3]候診室的墻角邊有個(gè)“自助醫(yī)護(hù)艙”，里面有電腦、血壓儀和體重秤各一臺(tái)，以供大家自行測(cè)量體征。

“關(guān)鍵在于如何應(yīng)對(duì)需求?！笔返俜颉つ獱栣t(yī)生說(shuō)。他是這家診所的九名內(nèi)科醫(yī)生之一，也是英國(guó)皇家全科醫(yī)學(xué)院的發(fā)言人。

[4]近年來(lái)，診所的就診需求大幅上升。不同尋常的是，這種上升并非體現(xiàn)在患者數(shù)目增加（實(shí)際上還有所減少），而是人們壽命延長(zhǎng)后出現(xiàn)更多愈發(fā)復(fù)雜的疾病。莫爾說(shuō)他每天要接診40到50個(gè)患者，其中60%當(dāng)面就診，其余通過(guò)電話就診。

“我的門診時(shí)間更長(zhǎng)了。”莫爾說(shuō)。一次門診是指用半天時(shí)間接待患者，一般每次門診持續(xù)三小時(shí)。而他的門診時(shí)間通常起碼要五小時(shí)。

[6] Despite their differences, the patients at this clinic—and anywhere else in the UK—have one thing in common:Not one of them will pay or receive a bill for the care they receive here.

Their health care is free and universal and has been since the formation of the country’s National Health Service13國(guó)民醫(yī)療服務(wù)體系，簡(jiǎn)稱NHS，1948年由當(dāng)時(shí)的工黨政府創(chuàng)立，為全民提供免費(fèi)醫(yī)療服務(wù)。英國(guó)NHS是世界上最大的公共基金醫(yī)療服務(wù)體系，所有經(jīng)費(fèi)來(lái)源于國(guó)家稅收，其運(yùn)營(yíng)由英國(guó)衛(wèi)生部監(jiān)管。NHS為居住在英國(guó)的人提供由生到死的全面醫(yī)療服務(wù)。不論個(gè)人收入多少、是否為納稅人，只要在英國(guó)有居留權(quán)，就可以享受免費(fèi)的醫(yī)療服務(wù)。in 1948.

[7] The population’s health care is funded through tax and compulsory14compulsory強(qiáng)制的。national insurance contributions15contribution（醫(yī)療保險(xiǎn)、養(yǎng)老金等）定期繳款。deducted from income, which go toward many state bene fi ts.

But as the demand for health care has increased across all levels of care—primary, secondary and tertiary16NHS實(shí)行分級(jí)醫(yī)療制，由三個(gè)層級(jí)的診療體系構(gòu)成：一級(jí)診療由全科醫(yī)生（General Practitioner，簡(jiǎn)稱 GP）和家庭診所提供，主要針對(duì)常見(jiàn)病、吸毒酗酒、輕微病癥人群，NHS資金的75%用于這部分；二級(jí)診療服務(wù)由地區(qū)性綜合醫(yī)院提供，醫(yī)院的規(guī)模根據(jù)地區(qū)人口密度來(lái)確定，主要針對(duì)初級(jí)診療難以治愈的急重癥患者；三級(jí)診療服務(wù)由專科醫(yī)院和教學(xué)醫(yī)院提供，接收二級(jí)機(jī)構(gòu)轉(zhuǎn)診來(lái)的病患，主要解決?？祁I(lǐng)域的疑難醫(yī)療問(wèn)題，比如癌癥。—so has the strain on this once-coveted17covet渴望；覬覦。health system—particularly on its fi nances.

A changing climate for health care

[8] Health care budgets in the UK have been plateauing18plateau保持穩(wěn)定水平。, with only minor increases in spending, as percentages of gross domestic product spent on it have been declining.

[5]莫爾的病人來(lái)源廣泛，診所覆蓋到的地區(qū)都有他的患者。有無(wú)家可歸的人、新來(lái)的難民、藍(lán)領(lǐng)工人，也有高薪的中產(chǎn)階級(jí)和律師，以及坐擁百萬(wàn)豪宅的銀行家。在當(dāng)?shù)啬苈?tīng)到1 4 0多種語(yǔ)言。

[6]盡管有這樣那樣的不同，來(lái)到這家診所的患者，以及英國(guó)其他地方的患者，有一個(gè)共同點(diǎn)：他們?cè)谶@個(gè)國(guó)家看病都不用花錢。

在英國(guó)，自1948年國(guó)民醫(yī)療服務(wù)體系（NHS）創(chuàng)立以來(lái)，人人都能享受免費(fèi)的醫(yī)療服務(wù)。

[7]英國(guó)的醫(yī)療資金來(lái)自從收入中扣除的稅款和強(qiáng)制性國(guó)民保險(xiǎn)繳款，這些錢會(huì)用作多項(xiàng)國(guó)家福利金。

然而，隨著各個(gè)層級(jí)（一級(jí)、二級(jí)和三級(jí)）診療服務(wù)需求的增加，一度令人艷羨的醫(yī)療體系也遭受了更大的壓力，財(cái)務(wù)狀況尤為緊張。

[9] Along with this came more people, who are living longer and with multiple conditions like diabetes and heart disease that require treatments also rising in cost. Meanwhile, hospital bed numbers have fallen, numbers visiting emergency rooms have risen, and the demand for social care—such as home care or equipment—in the community has increased with limited services in place to provide it, again leaving more people with fewer hospital beds.

[10] Austerity19austerity（經(jīng)濟(jì)）緊縮；嚴(yán)格節(jié)制消費(fèi)。has brought extended wait times for people seeking elective or routine treatments, such as knee or hip surgery, while emergency treatments for serious issues such as cancer or heart attacks continue to be treated promptly, as they should, according to Mowle.

Guidance requires anyone in the UK with signs of cancer be seen within two weeks.

[11] “(But) you can’t bring patients in for elective20elective可選擇的；非急需的。surgeries,” said Dr. Ian Eardley, vice president of the Royal College of Surgeons21英國(guó)皇家外科醫(yī)學(xué)院，成立于1800年，致力于推動(dòng)外科醫(yī)療發(fā)展、規(guī)范手術(shù)。in the UK and practicing22prac-tice從事（醫(yī)務(wù)工作、法律專業(yè)等）。surgeon at a hospital in Leeds.

醫(yī)療形勢(shì)正在轉(zhuǎn)變

[8]英國(guó)的醫(yī)療預(yù)算一直處于平穩(wěn)水平，支出上僅有小幅增長(zhǎng)，國(guó)內(nèi)生產(chǎn)總值中醫(yī)療支出方面的占比在不斷下降。

[9]與此同時(shí)，更多人壽命延長(zhǎng)卻罹患糖尿病和心臟病等多種疾病，這些疾病的治療成本也不斷增加。同時(shí)，醫(yī)院的床位減少，急診就診人數(shù)增加，社區(qū)里對(duì)社會(huì)照護(hù)（如家庭護(hù)理或醫(yī)療設(shè)備）的需求增多，但現(xiàn)成的服務(wù)機(jī)構(gòu)有限，再次出現(xiàn)患者多、床位少的局面。

[10]莫爾說(shuō)，由于開(kāi)支緊縮，需做膝蓋或髖部手術(shù)等非急需或常規(guī)治療的患者，等候手術(shù)的時(shí)間延長(zhǎng)了；而癌癥或心臟病等重癥仍能得到應(yīng)得的及時(shí)治療。

相關(guān)指導(dǎo)文件規(guī)定，在英國(guó)，任何人出現(xiàn)癌癥癥狀，都應(yīng)在兩周內(nèi)得到治療。

[11]“（可是）無(wú)法接診非急需手術(shù)的病人?！币炼鳌ざ虻吕t(yī)生說(shuō)。他現(xiàn)任英國(guó)皇家外科醫(yī)學(xué)院副院長(zhǎng)，也是利茲某醫(yī)院的外科醫(yī)生。

“人們的壽命延長(zhǎng)，往往有別的健康問(wèn)題需加以控制和應(yīng)對(duì)。”他還說(shuō)，如今患者的期望更高，往往還希望更詳細(xì)地討論病情，這些都使已然不堪重負(fù)的醫(yī)療體系負(fù)擔(dān)更重，不僅增加處理時(shí)間，壓力也會(huì)加大。

“People often live longer with other medical problems being controlled and managed,” he said, adding that greater expectations by patients today and the tendency to discuss cases in greater detail all add time and strain to an already overwhelmed23overwhelm壓倒；擊敗。system.

Is more spending better for health care?

[12] The UK spring budget for 2017 pledged24pledge保證給予。￡2 billion ($2.5 billion) toward adult social care over the next three years to “ease pressure on the NHS.”

￡425 million ($525 million) was also announced to be invested in the NHS in the next three years, with ￡100 million($125 million) going to Accident and Emergency departments in 2017—18, to help them manage increasing demand.

[13] Experts like McKee and Eardley welcome the investment, but believe it will not be enough. McKee highlighted Germany and France, which have more beds per capita, more doctors per 1,000 people and longer life expectancies25life expectancy預(yù)期壽命。.

[14] Germany and France use a social insurance model to pay for their health care: Deductions are taken from income, but unlike in the US, everyone is covered, and companies don’t make a pro fi t. Those contributing also “own”the organizations involved through boards and unions, McKee said.

醫(yī)療支出越多越好？

[12]英國(guó)政府承諾從2017年春季財(cái)政預(yù)算中撥款20億英鎊（約合25億美元），用于未來(lái)三年的成人社會(huì)照護(hù)，以此 “緩解NHS的壓力”。

同時(shí)宣布未來(lái)三年將對(duì)NHS投資4.25億英鎊（約合5.25億美元），其中1億英鎊（約合1.25億美元）在2017至2018年投向急診部門，幫助他們應(yīng)對(duì)日益增長(zhǎng)的需求。

[13]麥基和厄德利等專家樂(lè)見(jiàn)此舉，但他們認(rèn)為這些投資還不夠。麥基強(qiáng)調(diào)，德國(guó)和法國(guó)的人均床位更多，每千人對(duì)應(yīng)的醫(yī)生數(shù)量更多，人口預(yù)期壽命更長(zhǎng)。

[14]德國(guó)和法國(guó)使用一種社會(huì)保險(xiǎn)模式來(lái)為醫(yī)療服務(wù)買單：費(fèi)用從收入中扣除，但與美國(guó)不同的是，每個(gè)人都能享受到醫(yī)療保障，公司不會(huì)從中謀利。麥基說(shuō)，出資人以董事會(huì)和工會(huì)的形式“共同擁有”醫(yī)療機(jī)構(gòu)。

People pay a fee at the point of care,though it’s just $5 to $11 in Germany and $25 in France, which is often reimbursed26reimburse償還；補(bǔ)償。.

[15] The Western country spending the most on its health care is the US,which spent 17.1% of its GDP on health care in 2014.

Yet a series of factors—such as a lower life expectancy and uneven coverage—highlight that increased expenditure27expenditure花費(fèi)；開(kāi)支。alone is not always a good thing. A system to manage it best is key.

[16] McKee added that the private insurance-based model in the US, covering only those who are insured, leads to companies in the industry working toward pro fi t.

According to the Royal College of General Practitioners, the UK pays the least per patient than most countries in the West.

[17] In comparison with the US, Europe’s universal coverage, with tax- and social-fund-based financing through contributions, spends less and has more care that’s better, according to McKee.

Many countries on the continent still have a small sector of patients using private insurance. In the UK, an estimated 11% of the population has private insurance, often through their employers. In Germany, top earners can opt out of the public system and pay privately instead,representing an estimated 10% of Germans.

人們?cè)诳床r(shí)付費(fèi)，不過(guò)在德國(guó)只付5到11美元，在法國(guó)只要25美元，這筆費(fèi)用通常還能報(bào)銷。

[15]在醫(yī)療上花費(fèi)最多的西方國(guó)家是美國(guó)。2014年，美國(guó)GDP 17.1%用于醫(yī)療。

然而，一系列因素——如預(yù)期壽命較低、享受醫(yī)保的程度高低不均——充分表明僅僅增加開(kāi)支并不總是好事。建立一個(gè)良性運(yùn)轉(zhuǎn)的體制才是關(guān)鍵。

[16]麥基接著說(shuō)，美國(guó)采用以私人保險(xiǎn)為主的模式，只保障交了保險(xiǎn)的人，這使得保險(xiǎn)公司只求獲利。

英國(guó)皇家全科醫(yī)學(xué)院稱，在大多數(shù)西方國(guó)家中，英國(guó)病人的平均醫(yī)療花費(fèi)最低。

[17]麥基稱，和美國(guó)相比，歐洲國(guó)家全民參保，通過(guò)稅款和社會(huì)基金，以定期繳款的形式出資，這樣的模式花費(fèi)更少，能得到更多、更好的醫(yī)療服務(wù)。

歐洲大陸的許多國(guó)家仍然有小部分患者購(gòu)買私人保險(xiǎn)。在英國(guó)，估計(jì)11%的人口有私人保險(xiǎn)，通常由雇主出錢。在德國(guó)，最高收入人群可選擇不參加公共醫(yī)保，而是自費(fèi)，估計(jì)有10%的德國(guó)人這么做。

What is health care?

[18] “Health care should be free at the point of delivery28delivery遞送；交付。,” said Dr. Richard Kerr,a council member of the Royal College of Surgeons in the UK and consultant neurosurgeon29neurosurgeon神經(jīng)外科醫(yī)師。at a large regional hospital in Oxford. “There is a fee structure behind it, but when a patient comes to see me ... the issue of money never comes into it30not come into it無(wú)關(guān)緊要。.”

[19] Kerr believes countries worldwide can learn from those on mainland Europe,such as Germany and France, where the population receives great care, in his opinion, with good quality but pays more for it through taxes. “They are taxed higher but have much more investigative health care,” Kerr said.

[20] With the UK being more costefficient, he ponders whether that is something to be proud of. “If you receive the same level of care with less money,” that is indeed a point of pride.But with patient waiting times up to 20 weeks in some cases, he added, that is not the case.

什么是醫(yī)療？

[18]“醫(yī)療服務(wù)應(yīng)免費(fèi)提供。”理查德·克爾醫(yī)生說(shuō)。他現(xiàn)任英國(guó)皇家外科醫(yī)學(xué)院理事，也是牛津某大型區(qū)級(jí)醫(yī)院神經(jīng)外科顧問(wèn)醫(yī)師?！斑@種制度自有其費(fèi)用結(jié)構(gòu)，但患者來(lái)找我看病時(shí)，從來(lái)不需要擔(dān)心錢的問(wèn)題?！?/p>

[19]克爾認(rèn)為世界各國(guó)都可以向歐洲大陸學(xué)習(xí)，比如學(xué)德國(guó)和法國(guó)的做法，這些國(guó)家的人享受到優(yōu)質(zhì)的醫(yī)療服務(wù)，雖說(shuō)因此要繳更多的稅?！八麄兊亩惱U得更多，但得到的醫(yī)療服務(wù)要細(xì)致得多。”

[20]英國(guó)的做法成本效益更高，但克爾琢磨這是否值得驕傲?！坝酶俚腻X得到同等質(zhì)量的醫(yī)療服務(wù)，”那才值得驕傲。但他補(bǔ)充說(shuō)道，有些情況下，患者等候時(shí)間長(zhǎng)達(dá)20周，那就不是一回事了。

[21] The neuroscience department at his hospital in Oxford is the regional hospital, a point of tertiary care where patients requiring specialist procedures31procedure手術(shù)。are referred from their district hospitals.It serves more than 2.8 million people across a 100-mile radius32radius半徑范圍；周圍。, said Kerr,with just 60 beds in his main ward33ward病房。and another 13 in the intensive care unit34intensive care unit簡(jiǎn)稱ICU，重癥監(jiān)護(hù)室。.

[22] As he walks through the wards,he highlights the shuf fl ing35shuffle移來(lái)移去；反復(fù)挪動(dòng)。he and his team do on a regular basis between main wards and the ICU to ensure that all patients can access a bed and undergo their procedures.

But he shows further frustration with the lack of social care resources for patients away from his hospital, such as the provision of home carers or equipment to keep them mobile, or changes to make their homes more accessible or to help them access day centers. These are crucial, he believes, particularly as the population continues to live longer.

“Health care is incredibly complex. ...The growing number of older people with multi-morbidities36morbidity疾病。are having very very complex trajectories37trajectory軌跡。through the health and social care system,” McKee said. “We shouldn’t underestimate the challenges.”■

[21]克爾所在的牛津某醫(yī)院的神經(jīng)外科是區(qū)級(jí)診療中心，屬于三級(jí)醫(yī)療站點(diǎn)，需要?jiǎng)訉？剖中g(shù)的患者由片區(qū)醫(yī)院轉(zhuǎn)診到這里。克爾稱，這家醫(yī)院接待方圓100英里的280萬(wàn)民眾，而他負(fù)責(zé)的主要病房只有60個(gè)床位，還有13個(gè)在重癥監(jiān)護(hù)室。

[22]克爾穿過(guò)病房，他強(qiáng)調(diào)自己和團(tuán)隊(duì)會(huì)定時(shí)巡視主要病房和重癥監(jiān)護(hù)室，確保所有患者能有床位并順利手術(shù)。

但是，他也表達(dá)了深深的憂慮，因?yàn)樗牟∪穗x開(kāi)醫(yī)院后缺乏社會(huì)照護(hù)資源，例如難以提供家庭護(hù)工或幫助他們移動(dòng)的設(shè)備，或者難以進(jìn)行住家或日間護(hù)理站的無(wú)障礙設(shè)施改造。他認(rèn)為，這些資源至關(guān)重要，特別是在人口壽命不斷延長(zhǎng)的情況下。

“醫(yī)療系統(tǒng)非常復(fù)雜?！ㄟ^(guò)醫(yī)療和社會(huì)照護(hù)體系接受醫(yī)療服務(wù)的過(guò)程極其復(fù)雜，越來(lái)越多罹患多種疾病的老年人在經(jīng)歷著這樣的過(guò)程?！丙溁f(shuō)，“我們不該低估眼前的挑戰(zhàn)?！?□