英国“购买与提供分开”下的健康服务整合改革及启示

A people-centered integrated health service system is an important direction for the development of the current international health system. Given the leading position of the comprehensive performance of the UK health system among developed countries, under the framework of "separation of purchasing and provision", the government is responsible for both financing and service organization structures, which has similarities with China's health system. Based on literature research and on-site investigations, this article analyzes the internal logic and practical progress of the UK in building a people-centered integrated health service system in recent years and explores its implications for China. The research findings show that the reforms are mainly reflected in three levels: at the regional level, promoting the unified planning of various institutions within the health sector and cross-sector services, supplemented by transformation funds, performance evaluations, and integrated budget allocation and decision-making mechanisms; at the local level, promoting the coordination of services around population health through the integration of financing for public health and medical services to address health problems at the population level; at the community level, reorganizing the practice model of general practitioners, combining community services on the basis of the primary health network, and comprehensively addressing the determinants of health at the individual and community levels. Based on the UK experience, this article proposes that integration reforms involve multiple levels and their respective rights and responsibilities should be clearly defined; unified decision-making accountability and coordinated resource allocation are the key means to promote integration; the development of primary health care requires organization on the basis of specialization.

以人为本的整合型卫生服务体系是当前国际卫生体系发展的重要方向。鉴于英国卫生体系综合绩效在发达国家中的领先地位，在'购买与提供分开'的框架下政府同时负责筹资和服务组织的结构，这与我国卫生体系具有相似性，本文根据文献研究和现场调查，分析英国近年建设以人为本整合型卫生服务体系的内在逻辑和实践进展，并探讨其对我国的启示。研究发现，改革主要体现在三个层面：区域层面推动卫生部门内部各机构与跨部门服务的统一规划，并辅以转型基金、绩效考核和整合式的预算分配与决策机制；地方层面以公共卫生和医疗服务的筹资整合推动服务围绕人群健康进行协调，应对人群层面的健康问题；社区层面通过对全科医生执业模式进行再组织，在基层卫生网络基础上结合社区服务，综合应对个体和社区层面的健康决定因素。根据英国经验，本文提出：整合改革涉及多个层面，应当明确各自权责；统一的决策问责、协调的资源分配是推动整合的关键抓手；基层卫生发展需要在专业化基础上进行组织化。