性诊所竞争改良英国国家医疗服务体系

FOR THE easily embarrassed, getting tested for a sexually transmitted infection (STI) is a less excruciating process than it used to be. A kit is delivered to the patient’s home in plain packaging, no more than 48 hours after it is ordered, typically including a container for a urine sample, a swab or the tools for a blood test. The test is done at home and, once returned, results are delivered by text, within four days. Nervous types who want to avoid a trip to their local clinic will be glad that this free service is now available in areas including Birmingham, Essex, Norfolk and much of London.

对于容易感到尴尬的人来说，接受性传播感染（STI）测试没有过去那么不堪了。测试仪在订购后48小时内就会以平常包装送到患者家中，通常包括尿样器皿、拭子或血液检测工具。在家里完成测试后，寄送回诊所，测试的结果将在四天内通过短信发送至患者手中。让不想去当地诊所走一趟，容易紧张的人高兴的是，现在英国一些地区免费提供这项服务，范围包括伯明翰、埃塞克斯、诺福克和伦敦一部分地区。

A decade ago sexual-health clinics tended to be conservative facilities, hidden away in quiet corners of hospitals. Since then there has been something of a consumer revolution. Clinics have become more open, tech-savvy and attentive to their users, who are growing in number. Despite cuts of 14% to local-authority funding of such services between 2013 and 2017, the number of visits to sex clinics rose by 13%, to 3.3m a year. At a time when the health service is rethinking how it operates, the burst of innovation in sex clinics holds lessons for other parts of the NHS.

十年前，性健康诊所往往是保守性机构，通常隐藏在医院的安静角落。此后出现了一次消费者革命。性健康诊所变得更加开放、技术也更加精湛，且对他们的客户非常关心，他们的用户数量正在增长。尽管在2013年至2017年期间，英国地方政府对此类服务的资金支持减少了14％，但对性诊所的访问人数却增加了13％，达到每年330万人次。在卫生服务部门重新思考其运作模式的时候，性诊所的爆炸式创新为英国国家医疗服务体系（NHS）的其他部门提供了经验。

Sexual-health services have been given a boost by improvements in HIV care. Finding people who have the disease is a priority in public health, because with treatment they will no longer pass on the infection and can now lead long, healthy lives. But there are also organisational reasons for the innovation. In most of the NHS, patients are sent to specialist services by GPs, or family doctors, who act as gatekeepers. By contrast, anyone can walk into a sex clinic without a referral. As a result there is a strong incentive for clinics to attract patients, who bring funding and help doctors with research, says Axel Heitmueller of Imperial College Health Partners, a network of health-innovation experts.

艾滋病毒医护的改善促进了性健康服务行业。找到艾滋病患者是公共卫生部门的首要任务，因为通过治疗，他们可以停止传染给其他人，现在的技术也可以大大延长患者寿命，让他们过上健康的生活。不过，这种创新也有组织层面的原因。大多数NHS机构当中，担任守门人一职的全科医生或家庭医生送到专科医疗服务机构。相比之下，任何人去性诊所看病都不需要转诊手续。帝国理工学院健康合伙的Axel Heitmueller表示，诊所会有很大的吸引患者的动力，因为他们为医生提供资金并帮助医生开展研究。

In parts of the country with multiple specialist providers, there is also competition between clinics. As one clinician in London puts it, “There is a sense of keeping up with the Joneses.” 56 Dean Street, which opened in 2009 in Soho, London’s gay village, was a pioneer. On a Friday lunchtime it does a brisk trade as a diverse crowd pops in to use its services. Two members of staff were given freedom by the local NHS trust to come up with a new approach, tailored to the needs of patients. The result mixes sharp design, a central location and convenient services. Next came Dean Street Express, an automated facility which gives users quick results.

在英国一些地方有多家专业医疗服务机构，诊所之间也存在竞争。正如伦敦的一位临床医生所说：“有一种跟别人攀比的感觉。”迪恩街道56号（56 Dean Street）诊所2009年在伦敦同性恋村Soho开业，是这方面的先驱。在周五的午餐时间，当各种各样的人涌入该诊所寻求医疗服务时，它会快速进行交易。当地NHS信托基金会的两名工作人员可以自由根据患者的需求提出新的方法。结果融合了锐利的设计、中心位置和便捷的服务。接下来是迪恩街速递（Dean Street Express），这一自动化设施可以为用户快速提供结果。

Since then other trusts have opened more convenient clinics, including one under the arches by Waterloo station to target commuters. The focus on the lifestyle of users is apparent in other parts of the country, too. In Leicester a clinic will soon open in a shopping centre, replacing an old branch of TK Maxx, a discount fashion chain. Mobile clinics visit underserved districts or vulnerable groups. In rural areas, this means dropping by market towns. In urban ones it can mean hosting clinics in gay saunas. (There is “no obligation to use the sauna facilities”, the website assures.)

从那时起，其他信托基金机构设立更便利的诊所，其中包括在滑铁卢车站的拱门下开设一家诊所，目标用户为通勤人士。英国其他地区显然也很关注用户的生活方式。莱斯特的一家诊所很快将在购物中心开业，取代了折扣时尚连锁店TK Maxx的旧分店。移动诊所访问服务欠缺的地区或弱势群体。在农村地区，移动诊所可能开在集镇。在城市地区则可能在同性恋桑拿房（网站保证“没有义务使用桑拿设施”）。

Happy clappy

快乐的clappy

Trusts have been quick to copy good ideas, often from women’s or LGBT groups, who can offer insights into affected communities. Since 2003 free chlamydia self-testing kits have been offered to under-25s. Every year Public Health England, a government agency, funds pilot schemes (including one to spread HIV knowledge on prison radio and another to offer testing kits in vending machines).

信托基金一直以来都擅长快速复制好的想法，而这些想法通常来自女性或LGBT群体，对受影响社区提供不一样的见地。自2003年以来，免费的衣原体自测套装提供给25岁以下人群。每年，英国公共卫生部（Public Health England）作为政府机构，都会为试点项目（其中一个项目是在监狱电台传播HIV知识，还有一个是在自动售货机上提供检测套装）提供资金。

Innovation has helped to maintain standards at a time of tight budgets. Guy’s and St Thomas’ Trust in London has cut its number of sexual-health clinics from six to three, but helps more people than before, partly thanks to better use of technology to do things like manage queues and target high-risk patients. In some regions follow-ups for people being given the all-clear are now done by phone, rather than in person. The use of technology can lead to cock-ups: in 2016 the trust that runs 56 Dean Street was fined £180,000 ($236,000) after the clinic mistakenly copied 781 people into an email, revealing the identities of HIV patients. But on the whole it has made services more convenient, while driving down costs. STI self-testing costs the state around £25 a pop, a sixth of the cost of an initial visit to a clinic.

在预算紧张的情况下，创新有助于维持标准不变。伦敦的盖伊和圣托马斯信托基金将其性健康诊所的数量从六个减少到三个，但帮助的人却比以前更多，一个原因在于更好地利用技术来处理问题，比如管理排队现象，把目标放在高风险患者人群。在一些地区，现在对于完全康复的人群的后续跟进只需要通过电话完成，而不需要面对面。技术的使用可能导致吵架：2016年，经营迪恩街56号的信托公司被罚款180,000英镑（236,000美元），原因是这家诊所错误地将781人复制到电子邮件中，泄露了艾滋病患者的身份信息。不过，总的来说，它在提供更便利的服务的同时降低了成本。在英国，STI自测的花费为每人25英镑，是初次访问诊所的费用的六分之一。

Nevertheless, there are signs that the cuts may be harming accessibility. A mystery-shopping exercise published in 2017 found a fall in the proportion of people with STI symptoms who were able to get an appointment in 48 hours—a worrying finding at a time when rates of syphilis and gonorrhoea are rising. A big organisational shake-up has also caused disruption. In 2012-13 responsibility for commissioning sexual-health services (except HIV) moved from the NHS to local authorities. A survey by Public Health England found it hampered “seamless care”. It has also delayed the roll-out of pre-exposure prophylaxis (PrEP), a drug that protects against HIV.

尽管如此，有迹象表明成本的下降可能会损害方便性。2017年发布的一项神秘购物实验发现，STI症状的人数在48小时内实现预约的比例在下降，而在梅毒和淋病发病率上升时，这个研究发现让人感到担忧。一次重大的组织变革也造成了破坏。在2012至2013年间，健康服务（艾滋病毒除外）的责任从NHS转移到地方当局。英国公共卫生部的一项调查发现，它阻碍了“无缝护理”模式化，它阻碍了预防艾滋病毒的药物暴露前预防（PrEP）的推出。

Current NHS plans seek to overcome fragmentation (both in sexual-health services and elsewhere) by bringing providers and commissioners together, in the hope that they can work out how to raise standards. The example of sex clinics suggests it is worth thinking more about the incentives they have to innovate, whether coming from patient choice or elsewhere, says Mr Heitmueller. Changing behaviour is hard in any big organisation. Sexual selection offers one model for how it can be brought about.

目前的NHS的计划旨在通过将医疗服务提供机构和有关部门委员聚集在一起，解决（在性健康服务和其他领域）零碎化问题，以期能找到提高标准的办法。Heitmueller说，性诊所的例子表明，值得花更多的力气思考采取什么措施激励创新，这种创新可以来自患者选择也可以来自任何其他地方。任何大型组织要改变行为做法都是很困难的。性别选择则恰巧提供了一种能实现改变的模型。

编译：谷静

编辑：翻吧君

来源：经济学人（2019.03.16）

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