How Health Care Works Around the World

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

It’s Tuesday afternoon in the Hetherington Group Practice2practice（医生、律师的）工作地点。, 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位于伦敦南部，属于兰贝斯（Lambeth）区。20世纪初，这里是伦敦主要购物中心之一，以时髦和富庶而闻名。经历了二战后加勒比海移民带来的动荡，如今已成为一个多元文化区。.

[2] Adorning5adorn装饰。the many notice boards on the walls are posters asking people to get flu vaccinations6vaccination疫苗接种。, 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肠。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.伦

敦南部的一间候诊室内坐着三个人，他们年龄有别，种族各异，身边空着一大片绿色的塑料候诊椅子。

这是某个星期二的下午，地点是布里克斯顿闹市区的赫瑟林顿集团诊所。这家诊所为方圆几十英里的8500多位居民提供医疗服务。

[2]诊所的墙上有许多布告板，上面贴着各种海报：有的让人们接种流感疫苗；有的建议人们每天多走路；有的提醒人们一旦感觉有疑似肠癌的症状，要立即看医生。

还有一张海报告知人们当地医院的急诊室“并非人到病除”，呼吁大家不是紧急情况就不要去急诊室。

[3] In the corner of the waiting room sits a “patient pod9pod分离舱。” consisting of a computer, a blood pressure machine and scale, for people to measure their vitals10vitals=vital signs生命体征。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英国皇家全科医学院，成立于1952年，致力于维持全科医疗服务的最高标准。.

[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同类客户群体。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]候诊室的墙角边有个“自助医护舱”，里面有电脑、血压仪和体重秤各一台，以供大家自行测量体征。

“关键在于如何应对需求。”史蒂夫·莫尔医生说。他是这家诊所的九名内科医生之一，也是英国皇家全科医学院的发言人。

[4]近年来，诊所的就诊需求大幅上升。不同寻常的是，这种上升并非体现在患者数目增加（实际上还有所减少），而是人们寿命延长后出现更多愈发复杂的疾病。莫尔说他每天要接诊40到50个患者，其中60%当面就诊，其余通过电话就诊。

“我的门诊时间更长了。”莫尔说。一次门诊是指用半天时间接待患者，一般每次门诊持续三小时。而他的门诊时间通常起码要五小时。

[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国民医疗服务体系，简称NHS，1948年由当时的工党政府创立，为全民提供免费医疗服务。英国NHS是世界上最大的公共基金医疗服务体系，所有经费来源于国家税收，其运营由英国卫生部监管。NHS为居住在英国的人提供由生到死的全面医疗服务。不论个人收入多少、是否为纳税人，只要在英国有居留权，就可以享受免费的医疗服务。in 1948.

[7] The population’s health care is funded through tax and compulsory14compulsory强制的。national insurance contributions15contribution（医疗保险、养老金等）定期缴款。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实行分级医疗制，由三个层级的诊疗体系构成：一级诊疗由全科医生（General Practitioner，简称 GP）和家庭诊所提供，主要针对常见病、吸毒酗酒、轻微病症人群，NHS资金的75%用于这部分；二级诊疗服务由地区性综合医院提供，医院的规模根据地区人口密度来确定，主要针对初级诊疗难以治愈的急重症患者；三级诊疗服务由专科医院和教学医院提供，接收二级机构转诊来的病患，主要解决专科领域的疑难医疗问题，比如癌症。—so has the strain on this once-coveted17covet渴望；觊觎。health system—particularly on its fi nances.

A changing climate for health care

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

[5]莫尔的病人来源广泛，诊所覆盖到的地区都有他的患者。有无家可归的人、新来的难民、蓝领工人，也有高薪的中产阶级和律师，以及坐拥百万豪宅的银行家。在当地能听到1 4 0多种语言。

[6]尽管有这样那样的不同，来到这家诊所的患者，以及英国其他地方的患者，有一个共同点：他们在这个国家看病都不用花钱。

在英国，自1948年国民医疗服务体系（NHS）创立以来，人人都能享受免费的医疗服务。

[7]英国的医疗资金来自从收入中扣除的税款和强制性国民保险缴款，这些钱会用作多项国家福利金。

然而，随着各个层级（一级、二级和三级）诊疗服务需求的增加，一度令人艳羡的医疗体系也遭受了更大的压力，财务状况尤为紧张。

[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（经济）紧缩；严格节制消费。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可选择的；非急需的。surgeries,” said Dr. Ian Eardley, vice president of the Royal College of Surgeons21英国皇家外科医学院，成立于1800年，致力于推动外科医疗发展、规范手术。in the UK and practicing22prac-tice从事（医务工作、法律专业等）。surgeon at a hospital in Leeds.

医疗形势正在转变

[8]英国的医疗预算一直处于平稳水平，支出上仅有小幅增长，国内生产总值中医疗支出方面的占比在不断下降。

[9]与此同时，更多人寿命延长却罹患糖尿病和心脏病等多种疾病，这些疾病的治疗成本也不断增加。同时，医院的床位减少，急诊就诊人数增加，社区里对社会照护（如家庭护理或医疗设备）的需求增多，但现成的服务机构有限，再次出现患者多、床位少的局面。

[10]莫尔说，由于开支紧缩，需做膝盖或髋部手术等非急需或常规治疗的患者，等候手术的时间延长了；而癌症或心脏病等重症仍能得到应得的及时治疗。

相关指导文件规定，在英国，任何人出现癌症症状，都应在两周内得到治疗。

[11]“（可是）无法接诊非急需手术的病人。”伊恩·厄德利医生说。他现任英国皇家外科医学院副院长，也是利兹某医院的外科医生。

“人们的寿命延长，往往有别的健康问题需加以控制和应对。”他还说，如今患者的期望更高，往往还希望更详细地讨论病情，这些都使已然不堪重负的医疗体系负担更重，不仅增加处理时间，压力也会加大。

“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压倒；击败。system.

Is more spending better for health care?

[12] The UK spring budget for 2017 pledged24pledge保证给予。£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预期寿命。.

[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.

医疗支出越多越好？

[12]英国政府承诺从2017年春季财政预算中拨款20亿英镑（约合25亿美元），用于未来三年的成人社会照护，以此 “缓解NHS的压力”。

同时宣布未来三年将对NHS投资4.25亿英镑（约合5.25亿美元），其中1亿英镑（约合1.25亿美元）在2017至2018年投向急诊部门，帮助他们应对日益增长的需求。

[13]麦基和厄德利等专家乐见此举，但他们认为这些投资还不够。麦基强调，德国和法国的人均床位更多，每千人对应的医生数量更多，人口预期寿命更长。

[14]德国和法国使用一种社会保险模式来为医疗服务买单：费用从收入中扣除，但与美国不同的是，每个人都能享受到医疗保障，公司不会从中谋利。麦基说，出资人以董事会和工会的形式“共同拥有”医疗机构。

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偿还；补偿。.

[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花费；开支。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.

人们在看病时付费，不过在德国只付5到11美元，在法国只要25美元，这笔费用通常还能报销。

[15]在医疗上花费最多的西方国家是美国。2014年，美国GDP 17.1%用于医疗。

然而，一系列因素——如预期寿命较低、享受医保的程度高低不均——充分表明仅仅增加开支并不总是好事。建立一个良性运转的体制才是关键。

[16]麦基接着说，美国采用以私人保险为主的模式，只保障交了保险的人，这使得保险公司只求获利。

英国皇家全科医学院称，在大多数西方国家中，英国病人的平均医疗花费最低。

[17]麦基称，和美国相比，欧洲国家全民参保，通过税款和社会基金，以定期缴款的形式出资，这样的模式花费更少，能得到更多、更好的医疗服务。

欧洲大陆的许多国家仍然有小部分患者购买私人保险。在英国，估计11%的人口有私人保险，通常由雇主出钱。在德国，最高收入人群可选择不参加公共医保，而是自费，估计有10%的德国人这么做。

What is health care?

[18] “Health care should be free at the point of delivery28delivery递送；交付。,” said Dr. Richard Kerr,a council member of the Royal College of Surgeons in the UK and consultant neurosurgeon29neurosurgeon神经外科医师。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无关紧要。.”

[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.

什么是医疗？

[18]“医疗服务应免费提供。”理查德·克尔医生说。他现任英国皇家外科医学院理事，也是牛津某大型区级医院神经外科顾问医师。“这种制度自有其费用结构，但患者来找我看病时，从来不需要担心钱的问题。”

[19]克尔认为世界各国都可以向欧洲大陆学习，比如学德国和法国的做法，这些国家的人享受到优质的医疗服务，虽说因此要缴更多的税。“他们的税缴得更多，但得到的医疗服务要细致得多。”

[20]英国的做法成本效益更高，但克尔琢磨这是否值得骄傲。“用更少的钱得到同等质量的医疗服务，”那才值得骄傲。但他补充说道，有些情况下，患者等候时间长达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手术。are referred from their district hospitals.It serves more than 2.8 million people across a 100-mile radius32radius半径范围；周围。, said Kerr,with just 60 beds in his main ward33ward病房。and another 13 in the intensive care unit34intensive care unit简称ICU，重症监护室。.

[22] As he walks through the wards,he highlights the shuf fl ing35shuffle移来移去；反复挪动。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轨迹。through the health and social care system,” McKee said. “We shouldn’t underestimate the challenges.”■

[21]克尔所在的牛津某医院的神经外科是区级诊疗中心，属于三级医疗站点，需要动专科手术的患者由片区医院转诊到这里。克尔称，这家医院接待方圆100英里的280万民众，而他负责的主要病房只有60个床位，还有13个在重症监护室。

[22]克尔穿过病房，他强调自己和团队会定时巡视主要病房和重症监护室，确保所有患者能有床位并顺利手术。

但是，他也表达了深深的忧虑，因为他的病人离开医院后缺乏社会照护资源，例如难以提供家庭护工或帮助他们移动的设备，或者难以进行住家或日间护理站的无障碍设施改造。他认为，这些资源至关重要，特别是在人口寿命不断延长的情况下。

“医疗系统非常复杂。……通过医疗和社会照护体系接受医疗服务的过程极其复杂，越来越多罹患多种疾病的老年人在经历着这样的过程。”麦基说，“我们不该低估眼前的挑战。” □