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What David Cameron’s new patient safety tsar said five years ago. You might be surprised.

Roger Kline, 27 March 2013

Don Berwick is a world authority on patient safety. For two decades he led the US Institute for Health Improvement and he led the US president’s “Obamacare” reforms. In 2011 was forced to resign that post, partly for referring to the NHS as an example for the US to follow.

In 2008 he was quietly commissioned to report on the culture of the NHS by the then Chief Medical Officer Liam Donaldson. He reported a climate of “fear” but this did not become public until the Francis Inquiry into the Mid Staffordshire scandal.

Last month David Cameron announced Don Berwick had been asked to become NHS Patient Safety Tsar to lead a panel “to make zero harm a reality in our NHS”. Don't be surprised if their recommendations run counter to the government's 'reform' agenda.

In July 2008 Don Berwick wrote a 60th birthday message to the NHS in the British Medical Journal. In it he made ten suggestions for improving the NHS. His advice was so good, and so prefigures the Francis Report, that I thought I’d share it.

“First, put the patient at the center – at the absolute center of your system of care”. Berwick argues for “the active presence of patients, families, and communities in the design, management, assessment, and improvement of care, itself” rather than any reliance on focus groups or surveys.

“Second, stop restructuring.” In an echo of Francis he warns that it is destructive of time and confidence and leads to risk averse healthcare. Stability, he says, helps change “become easier and faster, as the good, smart, committed people of the NHS – the one million wonderful people who can carry you into the future – find the confidence to try improvements without fearing the next earthquake.”

“Third, strengthen the local health care systems – community care systems – as a whole.”  Health economies, not the fragmentation into individual elements like hospitals, clinics, surgeries, should become the “core of design”.

“Fourth, to help do that, reinvest in general practice and primary care”.  Berwick describes general practice, not the hospital, as “the jewel in the crown of the NHS”. 

Fifth, please don’t put your faith in market forces.” I’m not sure David Cameron read this bit before appointing him. Berwick scathingly says: “It’s a popular idea: that Adam Smith’s invisible hand would do a better job of designing care than leaders with plans can.  I do not agree. I find little evidence anywhere that market forces, bluntly used, that is, consumer choice among an array of products with competitors’ fighting it out, leads to the health care system you want and need. In the US, competition has become toxic; it is a major reason for our duplicative, supply-driven, fragmented care system. “

Sixth, avoid supply-driven care like the plague.” He warns, rightly, that the pursuit of institutional self-interest has helped make healthcare unaffordable in the USA

“Seventh, develop an integrated approach to the assessment, assurance, and improvement of quality.” He warned we needed a coherent system of “aim-setting, oversight, and assistance.” As Francis also discovered. 

"Eighth, heal the divide among the professions, the managers, and the government.”  This was another theme of the Mid Staffs report, made much worse by the rise of “general management” after the Griffiths Report of 1983. Berwick warned, again echoed by Francis, that “the NHS and the people it serves can ill afford another decade of misunderstanding and suspicion between the professions, on the one hand, and the managers and public servants, on the other hand.”

“Ninth, train your health care workforce for the future, not the past.” The new skills we need are those in “patient safety, continual improvement, teamwork, measurement, and patient-centered care".

“Tenth, and finally, aim for health.”  He warns that “great health care, technically delimited, cannot alone produce great health", and goes on: "Developed nations that forget that suffer the embarrassment of growing investments in health care with declining indices of health.  The charismatic epidemics of SARS, mad cow, and influenza cannot hold a candle to the damage of the durable ones of obesity, violence, depression, substance abuse, and physical inactivity.”

Don Berwick concluded the article by writing: “The only sentiment that exceeds my admiration for the NHS is my hope for the NHS. I hope that you will never, never give up on what you have begun. I hope that you realize and reaffirm how badly you need, how badly the world needs, an example at scale of a health system that is universal, accessible, excellent, and free at the point of care – a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just.  Happy birthday!”

Don Berwick’s own publications are a joy to read. You can also hear him in these two short videos. The first, ironically, was posted by an American free market think tank aiming to discredit him as being too left wing: it is indeed a brilliant two-minute defence of the NHS. The second summarises some key themes for good healthcare.

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