小郡三井医師会理事会　Nov. 14. 2005 　No.124

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定期配信日ではありませんが、重要な事項のためお知らせいたします。

◆ 会長から◆　

11月14日の読売新聞に東大名誉教授の大井玄さんの論文が掲載していましたのでお読みください。著作権の関係がありますので、転送は遠慮願います。

・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・

2005年11月14日　読売新聞より
大井　玄　東大名誉教授　専門は社会医学。70歳。

消費者主義導入は不適

医療費の適正化をめぐる最近の論議を聞くと、医療サービスへの期待が混乱しているように見える。問題の核心は、医療サービスは限られた資源を平等に利用すべき「公共財」なのか、通常の物や、サービスのような市場が評価する普通の財なのかという点である。
　戦後の日本や西欧諸国は前者の立場を、米国は後者の立場をとってきた。しかし、英国はサッチャー政権以来、競争原理や民間企業の手法を導入した。それがもたらした結果について、英国で権威ある医学誌『ランセット』は今年4月30日号の社説で、こう評価した。
　「すべての政治家が、医療サービスの改善を妨げる最も重要な要因への対応に失敗した。医師の破局的な士気低下である。国民医療保健制度（NHS）の下で、医師は全く勤労意欲を喪失している」　
　たしかに、英国の保健制度の効率の悪さは世界的に注目される。入院待ち患者が100万人を超え、入院までの平均待ち日数4か月、数万人が外科手術を1年以上待っている。しかし、この有り様でも、同国の医療は「平等」という正義が保たれているため、世界保健機関（WHO）は、6人に1人が医療保険のない米国よりも上位に評価する。米国は技術は高いが、正義に欠け、倫理的評価は低いというわけだ。
　『ランセット』誌の社説は、ブレア首相が率いる労働党政権が進める医療改革で、患者中心をうたう「消費者主義」を持ち込むことは間違いだと言う。
　その理由の一つに、医療サービスには市場経済原理は適用できないことを挙げる。市場経済は、消費者が十分な情報を平等に入手することを前提に、競争するゲームだが、医療でこの前提が成立した事例はない。情報へのアクセスは恐ろしく不平等だ。
　二つ目に、医療はみんなが利用する公共財であり、競争を持ちこめないと主張する。医療サービスは「平等」が垂要で、患者は消費者ではなく患者だ、という論理である。私には、この主張が妥当に思える。
　日本は、同誌が批判する英国と同じ道を歩みつつある。
　例えば、小児救急センターの小児科医は昼の仕事に続いて、一夜に50、60人の子どもを不眠不休で診る。入院は、100人に1、2人に過ぎないが、不安な親は納得のいく説明（情報）を要求してやまない。対応には時間が要る。待ち時間は延びる。しびれを切らした親はついにどなる。
「お前！2時間待たせやがって！」
　親は、当然な抗議行動だと思うかも知れない。しかし、真実を知らない。小児科救急は「志」の行為であり、営利事業ではないことを。小児科を生涯の天職にしよう、過酷な重労働でも誇りと生きがいを感じる若い医師が、親の一言で小児科を断念したことを。センターのやりくりがつかず、小児科救急医療がこうして崩壊しつつあることを。
　医療の正義を維持することは、重いみこしをかつぐことに似ている。全員に「忍耐」が求められる。自分だけが楽をする権利があると錯覚した時、みこしは土に落ち、崩壊する。

ランセットの本文を追加しておきます。

The Lancet 2005; 365:1515
DOI:10.1016/S0140-6736(05)66428-8
The unspoken issue that haunts the UK general election
Superbugs. Waiting times. Patient choice. More doctors. New investment. Efficiency savings. Foundation hospitals. National Health Service (NHS) reorganisation. Free personal care.
These are some of the issues that have been identified by the main political parties as battlegrounds for the UK election on May 5. The Economist, more likely, perhaps, to identify financial and business health as key issues, opted instead for the NHS as the "most important" subject in the campaign. But, sadly, Labour, Conservative, and Liberal Democrat politicians have all failed to address the single most important factor hindering the improvement of health services-the catastrophic collapse in morale among doctors.

Doctors at all levels within the NHS are utterly demoralised. They believe that targets have compromised patient care, undermining clinical decision making in favour of mostly irrelevant managerial gratification. They see the focus on shift work as fatally compromising ideals of professionalism, which are based on getting the job done properly irrespective of the time it takes to do so. They see a lack of continuity of care for large numbers of patients, increasing the likelihood of needless error. They are cynical about a new cadre of managers who have little clinical understanding but create a massively over-managed health service. And they feel let down by their own leaders, who have consistently failed to articulate a positive and assertive vision about the contribution modern medicine makes to society.
The strategic mistake made by politicians is to put the patient before everything else in the quest to achieve effective health care. To quote Labour: "One principle underpins our reforms-putting patients centre stage." Liberal Democrats pose a question: "Putting patients first. It is not asking much, surely?" And the Conservatives? While they pay lip service to professionalism, Conservative politicians offer few concrete proposals to restore medical morale. The mantra of patients having "the right" to select the hospital or doctor of their choice is repeated. The common error here is to make health an issue of power. Politicians believe that health-seeking behaviours can be equated with almost any other form of consumerism. They cannot. A successful market is the game consumers choose to play based on rules of competition and equal and maximum access to information. Yet none of these assumptions can ever be true in medicine. Health is not a game. It is a public good. Health services should not be about competition. They should be about equity. And access to information is appallingly unequal. Patients are not consumers. They are patients, pure and simple.
Too often, today, the debate about the NHS is based on a set of entirely false notions about what matters to patients. Nigel Crisp, the Chief Executive of the NHS, reminds the public that the NHS will prosper thanks to increased funding and more staff. He blithely assumes the continued commitment of health workers, without considering their attitudes to decades of political aggression aimed at the very values he is so proud to use in his own specious arguments. John Reid, the present Health Secretary, has spoken of a "personalised health service", one in which the patient takes control of decisions about the prescription of medicines and the selection of surgical procedures. Yet this attitude is manifest nonsense. If doctors have any role at all-and perhaps they do not in Dr Reid's world view-it is to establish a partnership with the patient. A partnership based not on power or untrammelled patient choice, but rather one based on mutual respect. Respect by the doctor for a patient's anxiety and care preferences. And respect by the patient for a doctor's skill and professional expertise.
Where are doctors' leaders in this debate? Mostly silent or out of touch. To be fair, the Royal Colleges, which could and should play a much fuller part in politics, are heavily constrained by their charitable status. They cannot appear to be partisan in their pronouncements. The British Medical Association, meanwhile, has only one unifying political message across general practitioners, consultants, staff and associate specialists, and juniors-more pay. It is no wonder that the public and mass media sometimes, although wrongly, see doctors as self-serving.
What UK medicine needs is a new and stronger political voice, one that is more concerned with augmenting professional standards than with protecting professional status. That voice does not exist at present. Doctors want to strengthen their professional morale because they know that a more robust and motivated profession will mean better outcomes for patients. Currently, no politician recognises this truth. May 5 will therefore not be about democracy at all. The public will be voting in a vacuum of fact. And our collective health will surely suffer the consequences.
The Lancet

丸山 泉

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社団法人小郡三井医師会　理事会

松尾武俊	平田弘美	西　奈々