J Public Health Policy. 1995;16(4):452-91.
The National Health Service provides (and throughout its lifetime of nearly 47 years has provided) comprehensive health care of the highest professional quality at both primary and specialist levels and at very low cost whether expressed in terms of GDP or cash when compared with other industrialised countries. Until the NHS market was introduced, administrative overheads were also strikingly low, between 5% and 6% compared with at least 22% in the US. The legislation imposing the NHS market represents a fundamental reorganisation and fragmentation of the NHS into competing services with a new bureaucracy of business and financial managements topslicing funds for patient care. It is the latest of a number of reorganisations dating from the first plans published by the Conservative administration in May 1971. Our calculations show that the newly imposed market processes have doubled the administrative running costs of the NHS. This represents an additional administrative expenditure of at least I.7 billion pounds a year at current prices. This sum therefore represents a diversion of 1.7 billion pounds a year from clinical services and goes some way to explaining the criticism from clinicians and the delays and inconvenience experienced by the public despite government claims that more money is being spent on the NHS. We describe the clandestine origins of the NHS market and note good and bad effects of its introduction. Because of their serious implications, we describe eleven damaging side-effects. These include the conflict between strategic planning of care and the operation of market forces. We identify other side-effects that are considered to be inseparable from market operation and sufficiently serious to call for urgent redress. We suggest how good effects associated with the introduction of the NHS market (such as giving GPs more say in the development of hospital services) could be enhanced without the side-effects inherent in the NHS market. We urge that ways of addressing these issues should, whenever possible, be piloted before they are introduced nationally. (In the case of fundholding in general practice, this damaging and controversial change should be halted and ways found to replace it with consortium commissioning, for which there is relevant experience.) We discuss the need to halt any other fundamental and potentially destabilising reorganisation before it has been tried out in properly evaluated pilot schemes. This should not, however, be allowed to become a recipe for stagnation as the health policy of the next government.
国民医疗服务体系（在其近47年的存续期间一直）以非常低的成本在初级和专科层面提供（并始终提供）最高专业质量的全面医疗保健服务，无论是与其他工业化国家相比，以国内生产总值或现金来衡量。在国民医疗服务体系引入市场机制之前，其管理费用也非常低，仅为5%至6%，而美国至少为22%。实施国民医疗服务体系市场机制的立法代表着国民医疗服务体系进行了根本性的重组和碎片化，变成了相互竞争的服务，还新增了商业和财务管理的官僚机构，从用于患者护理的资金中抽取资金。这是自1971年5月保守党政府公布首批计划以来一系列重组中的最新一次。我们的计算表明，新实施的市场机制使国民医疗服务体系的行政运营成本增加了一倍。按当前价格计算，这意味着每年至少额外增加17亿英镑的行政开支。因此，这笔钱相当于每年从临床服务中转移出17亿英镑，这在一定程度上解释了临床医生的批评以及公众所经历的延误和不便，尽管政府声称在国民医疗服务体系上投入了更多资金。我们描述了国民医疗服务体系市场机制的秘密起源，并指出了其引入的利弊。由于其严重影响，我们描述了十一个有害的副作用。这些包括护理战略规划与市场力量运作之间的冲突。我们还确定了其他被认为与市场运作不可分割且严重到需要紧急补救的副作用。我们建议如何在不产生国民医疗服务体系市场机制固有副作用的情况下，增强与引入该市场机制相关的良好效果（例如让全科医生在医院服务发展中有更多发言权）。我们敦促，解决这些问题的方法在全国推行之前，应尽可能先进行试点。（就全科医疗中的基金持有而言，这种有害且有争议的变革应停止，并找到用联合委托取代它的方法，对此已有相关经验。）我们讨论了在尚未在经过适当评估的试点计划中进行试验之前，停止任何其他根本性的、可能破坏稳定的重组的必要性。然而，这不应成为下一届政府卫生政策停滞不前的借口。
