【英语生活】患者至上

All this angry shouting about healthcare reform must be really bad for people's blood pressure. But it is no joking matter. “Health is wealth”, as they say. Nothing could be more serious.

In the heat of the debate taking place in the US, little light is being shed on what really matters: outcomes. But while the funding of healthcare is not a matter for this column, the management of it is. And it turns out that the task of introducing better healthcare for all is fundamentally a management challenge.

The Brits know this better than anybody. The UK's National Health Service was founded, in the face of bitter opposition, more than 60 years ago. It has been a vast, living experiment, and a monument to managerialism, good and bad.

Readers in the US may have heard some bizarre tales about the NHS in the past few days. I have not been able to keep up with all of them. But as a clarification I should point out that on the one hand, yes, state healthcare in the UK is effectively rationed as the public purse is not infinitely large. Politicians do not like admitting this, because it is unpopular. But it is true.

On the other hand, no; eminent and less eminent people are not simply left to die because they suffer from advanced cancer or severe physical handicaps. People with these conditions are not seen as “essentially worthless”, as one American journal put it. The physicist Stephen Hawking, who was cited as an example of a potential victim of the system, replied: “I wouldn't be here today if it were not for the NHS. I have received a large amount of high-quality treatment without which I would not have survived.” And for which, he might have added, he has paid not a penny piece, beyond his general tax bill.

But if the quality of care and outcomes varies in the NHS – and it does – this is not primarily because of the way the system is funded. It is because of the way it is managed. In the ongoing battle in the US, the health insurance companies can fight their own corner. Let us consider the management story instead.

Healthcare is a team-based activity. A family doctor needs good administrators and reception staff. A brilliant surgeon cannot perform without a competent anaesthetist, attentive theatre nurses and effective cleaners. The kitchen staff and porters play their own not insignificant part in getting hospital patients well.

Tom Peters, the management guru, has been on to this for some time. In a presentation last month for the American Hospital Association in San Francisco, he argued the case for more responsive, patient-centred healthcare that would in turn be more efficient and end up costing less to provide.

With his customary boldness he challenged his audience: “Do all the bits of your healthcare operation talk to, engage and consult obsessively with the other bits? Is the delivery of services truly a team effort? Are the patient and the patient's family at the epicentre of the universe?” Hospitals should be “one big innovation lab”, he declared.

He cited the work of Susan Frampton, Laura Gilpin and Patrick Charmel, in their book Putting Patients First, who argue that, far from being an inefficient or costly approach, teams that focus on “supportive interactions” get better results.

“Although labour costs are a substantial part of any hospital budget, the interactions themselves add nothing,” the authors say. “Kindness is free. Listening to patients or answering their questions costs nothing . . . Negative interactions – alienating patients, being non-responsive to their needs or limiting their sense of control – can be very costly.” Angry, frustrated or frightened patients end up needing far more attention, they say.

There are other examples of excellence in US healthcare – interestingly, often to be found at not-for-profit organisations. Kaiser Permanente, the California-based outfit, has established a strong reputation over six decades. More than half its 167,000 employees are union members, and management and staff speak positively about their working relationship. In 2008 Kaiser Permanente had revenues of $40bn.

Perhaps most famous of all, the Mayo Clinic in Rochester, Minnesota (also a not-for-profit organisation) has broken new ground in team-based, patient-centred healthcare. So much so that its methods have become the subject of a book (Management Lessons from Mayo Clinic, by Leonard Berry and Kent Seltman), studied closely by the leaders of many service sector companies.

What are the lessons from Mayo? Among others, they are: “solve the customer's total problem”; “turn customers into marketers”, “approach innovation as a discipline and a work in progress”; “hire for values”; “excellence is a journey”; and “challenge the performers to improve the performance”.

It is hard to avoid the conclusion that healthcare organisations should not really be trying to maximise revenue. Rather, they should be meeting the needs of their patients. They should be more customer-focused.

When the shouting in America has died down, perhaps politicians, healthcare professionals and insurers can turn their attention to this point.

围绕医改的一切愤怒喧嚣肯定对人们的血压极其不利。但这可不是开玩笑的事儿。常言道，“健康就是财富”。再没什么比这更严肃的问题了。

就在美国这场辩论进入白热化之际，真正要紧的问题却丝毫没有得到明晰：那就是结果。不过，尽管医疗的资金来源不在本专栏讨论范围之内，其管理却在。事实证明，为全体国民引入更好的医疗保健制度，从根本上讲是一项管理挑战。

英国人对这一点了解得比任何人都更清楚。英国国民保健服务(NHS) 60多年前是在一片激烈反对声中建立的。该体系已成为一项进行中的大型实验，管理主义的一座纪念碑，好坏兼而有之。

过去几天里，美国的读者们也许听说了一些关于NHS的怪诞故事。我未能知晓全部故事。但为了澄清事实，我应该指出的是，从一方面讲，没错，由于国库不是大得没边，英国的国家医疗服务实际上是定量配给的。政客们不愿承认这一点，因为这不得人心。但这的确是事实。

从另一方面讲，事实并非如此；不论对方是不是名人，都不会因其患上晚期癌症或存在严重生理缺陷而放手不管，让他等死。身患上述疾病的人并不像一家美国杂志所说的那样，被视为“本质上毫无价值”。该杂志将物理学家斯蒂芬•霍金(Stephen Hawking)列举为NHS体系潜在受害者的范例。霍金对此回应道：“如果没有NHS，我活不到今天。我接受了大量高质量的治疗，没有这些，我活不下来。”而且他或许还应补充一句，除了正常纳税，他没有为此付过一分钱。

但如果说NHS体系的医疗质量和结果参差有别——事实也的确如此——其主要原因并非整个体系的融资方式，而是其管理模式。在美国正在进行的这场论战中，健康保险公司大可为了自身利益据理力争。我们不妨转而考虑一下管理方面的问题。

医疗保健是一项团队活动。一名家庭医生需要优秀的行政助理和接待人员。一名出色的外科医生离不开称职的麻醉师、细心的手术室护士和得力的清洁员。住院患者能够康复，厨房工作人员和运输工各自的功劳也不可磨灭。

管理大师汤姆•彼得斯(Tom Peters)研究这一问题已有一段时间了。上月在旧金山为美国医院协会(American Hospital Association)做报告时，他主张建立响应能力更强、更以患者为中心的医疗体制，这反过来也将提高效率，并最终降低成本。

彼得斯以其惯有的大胆作风，向听众提出了质疑：“你们医疗运作体系中的所有部门会彼此交谈、沟通和协商，达到一种执迷的状态吗？你们的服务真的是团队努力的结果吗？患者和患者家属是一切工作的中心吗？”他宣称，医院应该是“一个巨大的创新实验室”。

他引用了苏珊•弗兰普顿(Susan Frampton)、劳拉•吉尔平(Laura Gilpin)和帕特里克•沙梅尔(Patrick Charmel)的研究成果。他们在合著的《患者至上》(Putting Patients First)中论证道，专注于“辅助互动”的团队不但不会效率低下或代价高昂，相反，会取得更好的成果。

“尽管在任何一家医院的预算中，人工成本都占了相当大的比重，但互动本身并不会增加任何费用，”他们表示。“仁慈之心是无偿的。聆听患者的需求、或回答他们的问题无需开销……负面的互动——疏远患者、对他们的需求无动于衷、或让他们感觉掌控能力有限——代价可能会相当高。”他们表示，愤怒、失落或恐惧的患者最终会需要多得多的关注。

美国医疗体系中还有其它一些杰出榜样——有趣的是，它们往往是非盈利组织。总部位于加州的Kaiser Permanente机构在过去60年里树立了极高的声誉。机构的16.7万名员工中，一半以上都是工会成员，管理层和员工对他们的工作关系都给予了积极评价。2008年，该机构收入高达400亿美元。

最著名的机构大概是位于明尼苏达州罗切斯特的梅奥诊所(Mayo Clinic)（同样是一个非盈利组织）。该机构在以团队为基础、以患者为中心的医疗领域开辟了一片新天地。其管理方法甚至成为了一本书的主题：伦纳德•贝里(Leonard Berry)和肯特•塞尔特曼(Kent Seltman)合著的《向世界最好的医院学管理》(Management Lessons from Mayo Clinic)，为众多服务行业公司的管理者认真研读。

我们从梅奥诊所那里汲取了哪些经验？ “解决顾客的全部问题”、“让顾客帮你营销”、“将创新视为一项行为准则和永不中止的工作”、“为价值观而招聘”、“卓越是一段历程”；以及“要求执行者不断改进表现”——这只是其中的一部分。

我们很难不得出这样的结论：医疗机构不应真的努力实现收入最大化。相反，它们应当致力于满足患者的需求，更加以客户为重。

当美国的喧嚣逐渐平息后，或许政界人士、医疗专家和保险公司能够将他们的注意力转到这一点上来。

译者/陈云飞