英国2012年《卫生和社会护理法案》研究
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摘要
英国通过1946年《国家卫生服务法案》(National Health Service Act 1946)将向全体公民提供近乎免费、平等的基本医疗服务变成一项国家义务,使得医疗服务从一项"私人产品"演变为法律上的"拟制公共产品"。2012年《卫生和社会护理法案》为迄今为止最广泛的国家卫生服务体系重组提供了法律依据。经济可持续性的考量推动了2012年《卫生和社会护理法案》的改革进程。我国相关立法应借鉴2012年《卫生和社会护理法案》界定相关主体职能(职权和职责),强化政府出资、监管职责,而非原则性规定政府直接提供服务。简政放权,培育市场,加强监管应是政府履行主导责任的最佳方式。鉴于目前的老龄化压力,我国应借鉴英国经验,尽快建立社会护理制度。
National Health Service Act 1946 provided for the establishment of a comprehensive health service for England and madethe Secretary of State's duty as to promote free and equal comprehensive health service clear. This act changed health services from "private products"to "legal fiction public products". The Health and Social Care Act 2012 provides for the most extensive reorganisation of the structure of the NHS in England to date. Economic sustainability has largely driven the reform process leading to the 2012 Act. In our basic health law,we should clarify the organizations' functions( power and duty),strengthen the government's duty as to investment and regulation,rather than only prescribe the legal requirement of provide services.The best ways for the government to fulfill its leading responsibilities are streamlining government and delegating authorities,strengthening supervision,improving the market system. Based on the pressure of a rapidly ageing population,we should learn from the British experience and establish a social care system as soon as possible.
National Health Service Act 1946 provided for the establishment of a comprehensive health service for England and madethe Secretary of State's duty as to promote free and equal comprehensive health service clear. This act changed health services from "private products"to "legal fiction public products". The Health and Social Care Act 2012 provides for the most extensive reorganisation of the structure of the NHS in England to date. Economic sustainability has largely driven the reform process leading to the 2012 Act. In our basic health law,we should clarify the organizations' functions( power and duty),strengthen the government's duty as to investment and regulation,rather than only prescribe the legal requirement of provide services.The best ways for the government to fulfill its leading responsibilities are streamlining government and delegating authorities,strengthening supervision,improving the market system. Based on the pressure of a rapidly ageing population,we should learn from the British experience and establish a social care system as soon as possible.
引文
(1)Sir David Nicholson's speech,NHS Alliance conference November 18,2010,参见www.healthpolicyinsight.com/?q=node/858,访问日期:2017年12月18日。
(2)Nicholas Timmins,Never Again?The story of the Health and Social Care Act 2012,The King’s Fund and the Institute for Government,2012,P.3.
(3)陈云良:《基本医疗服务法制化研究》,载《法律科学(西北政法大学学报)》2014年第2期,第76页。
(4)Martin Gorsky,The British National Health Service 1948-2008:A Review of the Historiography,Social History of Medicine,Volume 21,Issue 3,1 December 2008,P.1.
(5)Charles Webster,The National Health Service:a political history(2nd edition),Oxford University Press,2002.P.284.
(6)Peter Greengross,Ken Grant,The History and Development of The UK National Health Service 1948-1999,DFIDHealth Systems Resource Centre,Second Edition,July 1999,P.7.
(7)法案保障医疗卫生从业人员的经费,建立临床标准咨询小组,规定社区护理(Community care)。其修改1948年的《国家援助法案》第21条,规定地方当局对因年龄、疾病、残疾、无家可归的孕妇或其他情况具有提供膳宿的义务。此法案最大的贡献在于改革NHS信托财政制度,使卫生当局自己管理预算,并向医院和其他组织购买服务。
(8)Rudolf Klein,The New Politics of the NHS:From Creation to Reinvention(seventh edition),London and New York:Radcliffe Publishing,2013,P.332.
(9)Alain C.Enthoven,Internal Market Reform of the British National Health Service,Health Affairs,January 1991.
(10)包括血液供应、干细胞和骨髓的供应、移植或组织供应,以及匹配和分配在内的捐赠器官。
(11)Nicola Glover-Thomas,The Health and Social Care Act 2012:The emergence of equal treatment for mental health care or another false dawn?Med Law Int,2013 Dec13(4),P.279.
(12)健康社会决定因素如生活条件、收入水平、社会地位、所拥有的资源等。。
(13)Emily Jackson.Medical Law:test,cases,and materials(Fourth edition).Oxford University Press.2016.P.116
(14)Department of Health and Social Care:《Health and Social Care Act 2012:fact sheets》,https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138257/A1.-Factsheet-Overview-240412.pdf,访问日期:2017年11月1日。
(15)NHS England’s legal name is the National Health Service Commissioning Board.
(16)Commissioning本意为委任、命令、调试。卫生部给其定义为:The process of ensuring that the health and care services provided effectively meet the needs of the population.(确保卫生和护理服务有效地满足人们需求的过程)因此,该词被视为帮助实现广泛政策目标的关键手段,包括提高服务的安全性和质量;创造更好的资金价值和更广泛的病人选择;减少健康的不平等。这样的目标在一定程度上是通过在人口中公平分配资源来实现的。资源如何在人口中分配是由资源分配拨款决定的。可以认为,统筹是包括评估需求、规划服务、采购服务、监控质量在内的一系列活动。
(17)英国卫生体系分为初级卫生服务(primary medical services)和二级卫生服务(The secondary care services)。前者主要由全科医生,即通常所说的GP(general practitioner)以及牙医、护士、药剂师组成,包括军事卫生服务。后者主要包括专科医院、康复护理、社区服务、急救、精神卫生服务等。
(18)临床统筹委员会职能的总结,https://www.england.nhs.uk/wp-content/uploads/2013/03/a-functions-ccgs.pdf,访问日期:2017年12月11日。
(19)《2012法案》第34条。
(20)NHS改革的重要方向是希望NHS能独立运行。政府医改的目标之一是结束对NHS的政治干预。因此统筹委员会是保持相对独立的机构。
(21)McH ale Fox and Jean McH ale.Health Care Law:test,and materials(Second edition).London:Sweet&Maxwell,2007,p.7.
(22)在英国立法文件中,政府的相应职权和职责用functions指代,参见2006《NHS法案》第14编第275条术语解释中规定:“functions”includes powers and duties.
(23)卫生大臣是英内阁成员,主管卫生和社会护理部,是全国医疗卫生事业的第一责任人。相当于我国主管卫生工作的副总理,其可等同国家之代表。
(24)将职责从“provide or secure the provision of services in accordance with this Act”,改变为“exercise the functions conferred by this Act so as to secure that services are provided in accordance with this Act”。
(25)有人认为卫生大臣直接干预NHS将不可避免增加政治影响,因此增加了“显著”的限定条件。
(26)https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213748/dh_127540.pdf,访问日期:2017年10月8日。
(27)电离指伽马射线(gramma rays),X射线(X-rays)等,非电离(Non-ionising radiation)指的是光辐射(紫外线、红外线和可见光等)和电磁场(微波等)。http//www.hse.gov.uk/radiation/nonionising,访问日期:2017年11月29日。
(28)附件8强调了监管局的宪章和公众监督。
(29)《2012法案》第62条。
(30)NHS National Tariff Payment System系资金流动制度,其包含一系列价格和规则以确保服务提供者和统筹者以最优价格向患者提供服务。在按结果付费模式下(Payment by Results),National Tariff指代统筹者为临床治疗支付的价格。这种制度很大程度上依据国家平均成本(national average costs)。政府每年收集参考成本(reference costs)并汇编颁布。
(31)修改了《2006法案》中附表7的章程。
(32)它们最大的财务自由就是可以在借款限额内从公共和私营法人处筹集资金,并进行相应投资,产生盈利后再进行投资。这是由预计的现金流决定的,因此是基于负担能力的。它们正在逐步从中央政府控制中解放出来,不再由卫生当局管理,作为自立的、自治的组织。
(33)includes all forms of personal care and other practical assistance provided for individuals who,by reason of age,illness,disability,pregnancy,childbirth,dependence on alcohol or drugs,or any other similar circumstances,are in need of such care or other assistance;
(34)http://nisw.org.uk/socialcare/,访问日期:2017年12月4日。
(35)参见英国上议院备忘录:Hansard(House of Lords),21 May 2013,Vol.745,col.769.
(36)该法案通过引进大量《欧洲人权公约》的内容,确定了生命权(the right to life)、自由权(the right to liberty)等。
(37)https://www.gov.uk/government/publications/care-act-2014-part-1-factsheets/care-act-factsheets,访问日期:2017年11月9日。
(38)社会护理服务是国家单独资助的。NHS的费用体现在被护理者卫生服务的支出,比如急救(A&E)、家中化疗、患者用药等。因两种费用逐年上涨,因此英国不断整合两种服务。
(39)如果没有护理者的护理,孤寡老人很可能在家中跌倒。此时如无护理人员老人性命堪忧。即便老人呼叫了急救服务送往医院,亦将加大医院支出,甚至无法出院。护理、急救、医疗如不能很好协调,将对老人产生巨大不利影响。
(40)Care Quality Commission,The state of health care and adult social care in England 2016-17,P.18.
(41)Health and Social care Information Center,Community Care Atatistics,Social Services Activity in England-2013-2014(2014).
(42)The Board must exercise its functions with a view to securing that health services are provided in an integrated way.
(43)Explanatory Notes About Health And Social Care Act 2012,第222条,P.35.
(44)《2012法案》第26条。
(45)参见《2012法案》第23条。
(46)参见《2006法案》第9条第1款,《2012法案》对第9条进行了微小的修正。
(47)Mikey Smith,Jeremy Hunt has got a new job in Theresa May's Cabinet reshuffle after an hour inside Number 10,Daily Mirror,8 January 2018.
(48)http://www.cncaprc.gov.cn/contents/16/186225.html,访问日期:2017年11月8日。
(49)R V North and East Devon Health Authority,ex parte Coughlan案,[2001]QB213.
(50)Emily Jackson.Medical Law:test,cases,and materials(Fourth edition).Oxford University Press.2016,p.88.
(51)典型案例有:R(on the application of Rose)V Thanet Clinical Commissioning Group[2014]EWHC 1182等。
(52)此处指的是基因工程、辅助受孕、胚胎和干细胞、器官移植、安乐死、代孕等在医疗方面与伦理道德联系相对紧密的问题。
(53)以前,这些权利和责任是在普通法、成文法或欧盟法律中逐渐演变的,或将英政府、NHS政策承诺写入文件。它可以被看作是一种思想的发展,始于1991年《患者宪章》。附带的是一本手册,详细说明了支持这些权利、义务和责任的立法。这些立法主要包括:2009/2012/2014法案等。其中关于NHS问责的陈述也清楚地说明了NHS体系的问责制、透明度和责任。
(54)例如在立法的听证过程中,一项调查显示:有全科医生没有向超过1/3精神卫生服务的受益者提供治疗方案的选择。英国皇家助产士协会的回复报告中也阐明:产科服务的选择存在很多障碍。
(55)Marie Sanderson,The regulation of competition in the National Health Service(NHS):what difference has the Health and SocialC are Act 2012 made?Health Economics,Policy and Law(2017),12,P.1.
(56)Department of Health and Social Care,Government response to the NHS Future Forum report,https://www.gov.uk/government/publications/government-response-to-the-nhs-future-forum-report,访问日期:2017年11月1日。
(2)Nicholas Timmins,Never Again?The story of the Health and Social Care Act 2012,The King’s Fund and the Institute for Government,2012,P.3.
(3)陈云良:《基本医疗服务法制化研究》,载《法律科学(西北政法大学学报)》2014年第2期,第76页。
(4)Martin Gorsky,The British National Health Service 1948-2008:A Review of the Historiography,Social History of Medicine,Volume 21,Issue 3,1 December 2008,P.1.
(5)Charles Webster,The National Health Service:a political history(2nd edition),Oxford University Press,2002.P.284.
(6)Peter Greengross,Ken Grant,The History and Development of The UK National Health Service 1948-1999,DFIDHealth Systems Resource Centre,Second Edition,July 1999,P.7.
(7)法案保障医疗卫生从业人员的经费,建立临床标准咨询小组,规定社区护理(Community care)。其修改1948年的《国家援助法案》第21条,规定地方当局对因年龄、疾病、残疾、无家可归的孕妇或其他情况具有提供膳宿的义务。此法案最大的贡献在于改革NHS信托财政制度,使卫生当局自己管理预算,并向医院和其他组织购买服务。
(8)Rudolf Klein,The New Politics of the NHS:From Creation to Reinvention(seventh edition),London and New York:Radcliffe Publishing,2013,P.332.
(9)Alain C.Enthoven,Internal Market Reform of the British National Health Service,Health Affairs,January 1991.
(10)包括血液供应、干细胞和骨髓的供应、移植或组织供应,以及匹配和分配在内的捐赠器官。
(11)Nicola Glover-Thomas,The Health and Social Care Act 2012:The emergence of equal treatment for mental health care or another false dawn?Med Law Int,2013 Dec13(4),P.279.
(12)健康社会决定因素如生活条件、收入水平、社会地位、所拥有的资源等。。
(13)Emily Jackson.Medical Law:test,cases,and materials(Fourth edition).Oxford University Press.2016.P.116
(14)Department of Health and Social Care:《Health and Social Care Act 2012:fact sheets》,https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138257/A1.-Factsheet-Overview-240412.pdf,访问日期:2017年11月1日。
(15)NHS England’s legal name is the National Health Service Commissioning Board.
(16)Commissioning本意为委任、命令、调试。卫生部给其定义为:The process of ensuring that the health and care services provided effectively meet the needs of the population.(确保卫生和护理服务有效地满足人们需求的过程)因此,该词被视为帮助实现广泛政策目标的关键手段,包括提高服务的安全性和质量;创造更好的资金价值和更广泛的病人选择;减少健康的不平等。这样的目标在一定程度上是通过在人口中公平分配资源来实现的。资源如何在人口中分配是由资源分配拨款决定的。可以认为,统筹是包括评估需求、规划服务、采购服务、监控质量在内的一系列活动。
(17)英国卫生体系分为初级卫生服务(primary medical services)和二级卫生服务(The secondary care services)。前者主要由全科医生,即通常所说的GP(general practitioner)以及牙医、护士、药剂师组成,包括军事卫生服务。后者主要包括专科医院、康复护理、社区服务、急救、精神卫生服务等。
(18)临床统筹委员会职能的总结,https://www.england.nhs.uk/wp-content/uploads/2013/03/a-functions-ccgs.pdf,访问日期:2017年12月11日。
(19)《2012法案》第34条。
(20)NHS改革的重要方向是希望NHS能独立运行。政府医改的目标之一是结束对NHS的政治干预。因此统筹委员会是保持相对独立的机构。
(21)McH ale Fox and Jean McH ale.Health Care Law:test,and materials(Second edition).London:Sweet&Maxwell,2007,p.7.
(22)在英国立法文件中,政府的相应职权和职责用functions指代,参见2006《NHS法案》第14编第275条术语解释中规定:“functions”includes powers and duties.
(23)卫生大臣是英内阁成员,主管卫生和社会护理部,是全国医疗卫生事业的第一责任人。相当于我国主管卫生工作的副总理,其可等同国家之代表。
(24)将职责从“provide or secure the provision of services in accordance with this Act”,改变为“exercise the functions conferred by this Act so as to secure that services are provided in accordance with this Act”。
(25)有人认为卫生大臣直接干预NHS将不可避免增加政治影响,因此增加了“显著”的限定条件。
(26)https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213748/dh_127540.pdf,访问日期:2017年10月8日。
(27)电离指伽马射线(gramma rays),X射线(X-rays)等,非电离(Non-ionising radiation)指的是光辐射(紫外线、红外线和可见光等)和电磁场(微波等)。http//www.hse.gov.uk/radiation/nonionising,访问日期:2017年11月29日。
(28)附件8强调了监管局的宪章和公众监督。
(29)《2012法案》第62条。
(30)NHS National Tariff Payment System系资金流动制度,其包含一系列价格和规则以确保服务提供者和统筹者以最优价格向患者提供服务。在按结果付费模式下(Payment by Results),National Tariff指代统筹者为临床治疗支付的价格。这种制度很大程度上依据国家平均成本(national average costs)。政府每年收集参考成本(reference costs)并汇编颁布。
(31)修改了《2006法案》中附表7的章程。
(32)它们最大的财务自由就是可以在借款限额内从公共和私营法人处筹集资金,并进行相应投资,产生盈利后再进行投资。这是由预计的现金流决定的,因此是基于负担能力的。它们正在逐步从中央政府控制中解放出来,不再由卫生当局管理,作为自立的、自治的组织。
(33)includes all forms of personal care and other practical assistance provided for individuals who,by reason of age,illness,disability,pregnancy,childbirth,dependence on alcohol or drugs,or any other similar circumstances,are in need of such care or other assistance;
(34)http://nisw.org.uk/socialcare/,访问日期:2017年12月4日。
(35)参见英国上议院备忘录:Hansard(House of Lords),21 May 2013,Vol.745,col.769.
(36)该法案通过引进大量《欧洲人权公约》的内容,确定了生命权(the right to life)、自由权(the right to liberty)等。
(37)https://www.gov.uk/government/publications/care-act-2014-part-1-factsheets/care-act-factsheets,访问日期:2017年11月9日。
(38)社会护理服务是国家单独资助的。NHS的费用体现在被护理者卫生服务的支出,比如急救(A&E)、家中化疗、患者用药等。因两种费用逐年上涨,因此英国不断整合两种服务。
(39)如果没有护理者的护理,孤寡老人很可能在家中跌倒。此时如无护理人员老人性命堪忧。即便老人呼叫了急救服务送往医院,亦将加大医院支出,甚至无法出院。护理、急救、医疗如不能很好协调,将对老人产生巨大不利影响。
(40)Care Quality Commission,The state of health care and adult social care in England 2016-17,P.18.
(41)Health and Social care Information Center,Community Care Atatistics,Social Services Activity in England-2013-2014(2014).
(42)The Board must exercise its functions with a view to securing that health services are provided in an integrated way.
(43)Explanatory Notes About Health And Social Care Act 2012,第222条,P.35.
(44)《2012法案》第26条。
(45)参见《2012法案》第23条。
(46)参见《2006法案》第9条第1款,《2012法案》对第9条进行了微小的修正。
(47)Mikey Smith,Jeremy Hunt has got a new job in Theresa May's Cabinet reshuffle after an hour inside Number 10,Daily Mirror,8 January 2018.
(48)http://www.cncaprc.gov.cn/contents/16/186225.html,访问日期:2017年11月8日。
(49)R V North and East Devon Health Authority,ex parte Coughlan案,[2001]QB213.
(50)Emily Jackson.Medical Law:test,cases,and materials(Fourth edition).Oxford University Press.2016,p.88.
(51)典型案例有:R(on the application of Rose)V Thanet Clinical Commissioning Group[2014]EWHC 1182等。
(52)此处指的是基因工程、辅助受孕、胚胎和干细胞、器官移植、安乐死、代孕等在医疗方面与伦理道德联系相对紧密的问题。
(53)以前,这些权利和责任是在普通法、成文法或欧盟法律中逐渐演变的,或将英政府、NHS政策承诺写入文件。它可以被看作是一种思想的发展,始于1991年《患者宪章》。附带的是一本手册,详细说明了支持这些权利、义务和责任的立法。这些立法主要包括:2009/2012/2014法案等。其中关于NHS问责的陈述也清楚地说明了NHS体系的问责制、透明度和责任。
(54)例如在立法的听证过程中,一项调查显示:有全科医生没有向超过1/3精神卫生服务的受益者提供治疗方案的选择。英国皇家助产士协会的回复报告中也阐明:产科服务的选择存在很多障碍。
(55)Marie Sanderson,The regulation of competition in the National Health Service(NHS):what difference has the Health and SocialC are Act 2012 made?Health Economics,Policy and Law(2017),12,P.1.
(56)Department of Health and Social Care,Government response to the NHS Future Forum report,https://www.gov.uk/government/publications/government-response-to-the-nhs-future-forum-report,访问日期:2017年11月1日。