Klein R
Centre for the Analysis of Social Policy, University of Bath, UK.
Health Policy. 1994 Feb;27(2):103-12. doi: 10.1016/0168-8510(94)90075-2.
The case of Britain's National Health Service is used to illuminate the cross-national debate about whether the availability of health care should be restricted and, if so, how this should be done. Traditionally, the NHS relied on implicit rationing by clinicians within budgetary constraints set by government. However, the logic of the 1989 reforms appeared to require explicit decisions about the packages of health care to be provided to local populations. In practice, purchasers have refused to define such packages. Explicit rationing remains very much the exception. Exploring the reasons for this suggests that defining a restricted menu of health care, by adopting a cost-utility approach and excluding specific procedures or forms of treatment on the Oregon model, is only one of many policy options. There is a large repertory of policy tools for balancing demands and resources, ranging from diluting the intensity of treatment to its earlier termination. Given that health care is characterised by uncertainty, lack of information about outcomes and patient heterogeneity, it may therefore be more 'rational' to diffuse decision-making among clinicians and managers than to try to move towards a centrally determined menu of entitlements.
英国国民医疗服务体系的案例被用来阐明关于医疗保健的可及性是否应受到限制以及如果应受限制该如何实施的跨国辩论。传统上，国民医疗服务体系依赖临床医生在政府设定的预算限制内进行隐性配给。然而，1989年改革的逻辑似乎要求就向当地居民提供的医疗保健套餐做出明确决策。实际上，购买者拒绝界定此类套餐。明确配给仍然非常少见。探究其中的原因表明，采用成本效用方法并参照俄勒冈模式排除特定程序或治疗形式来界定有限的医疗保健菜单，只是众多政策选择之一。在平衡需求和资源方面有大量的政策工具，从降低治疗强度到提前终止治疗不等。鉴于医疗保健具有不确定性、缺乏关于治疗结果的信息以及患者的异质性，因此，与其试图转向由中央确定的应享权利菜单，不如将决策权分散给临床医生和管理人员，这可能更“合理”。
