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Two cheers for Berwick's report on patient safety in the NHS

Mon, 12th Aug 2013
There are plenty of things to approve in Don Berwick’s report on patient safety, as well as some to query. The fact that both good and less good are the opposite of what most people think they are says much about the state of public debate on the NHS as well as the difficulty of making the changes that Berwick recommends.
 
Overall response to the report has been lukewarm. It has been criticised as too general and short on particulars: no headline proposals for tough legal sanctions on individuals or regulation, no minimum staffing levels for wards (a ‘missed opportunity’, according to the nurses).  In fact these reflect what’s good about it. Along with other clear principles – constancy of purpose in minimising harm, suspicion of numerical targets, the need to drive out fear and build pride and joy in work, attributing blame to a bad system rather than bad individuals, turning the NHS into a learning organisation – they come straight out of the Deming management handbook. Real cheers, then, for a report that recognises that the NHS is a system, so that change has to be systemic too.
 
In fact, that was one of Berwick’s most important points: awful though events at Mid Staffordshire were, he noted in a Newsnight interview, the fact that the NHS was a single system meant that when things went wrong there was an opportunity to do improve them system-wide – an impossibility in the fragmented US, for example.
 
The problem is that many people – inside the NHS as well as out – won’t get the radical implications of the system point. Without being exposed to them in action, they rarely do. We prefer easy solutions to hard ones, and sound-bite-obsessed media don’t help. And for them, the report will indeed seem general and even comforting. Learning organisation, ‘culture change’ – what could be softer focus, less contentious than that? 
 
Paradoxically, one of the warning lights is the choice of patient safety as top priority. Of course, that’s what Berwick was asked to report on, and to be strictly accurate, it is ‘the quality of patient care, especially patient safety’, that the report singles out as the NHS’s most important aim. But safety and high-quality patient care, as Vanguard’s Andy Brogan, a keen and involved student of NHS affairs, points out, are ‘hygiene factors’, something necessary to achieve the purpose but not identical with it. Safety is a priority for air travel, too, but it’s not the purpose, and nor is it for the NHS.
 
‘When you have to make safety a priority, it tells you that the focus must have been wrong before’, Brogan reasons. ‘We ended up with a safety problem because we weren't focused on purpose and value. A patient safety focus is not the same as a focus on purpose and value and therefore doesn't remove the precipitating cause of the problem. It treats the symptom.’
 
The purpose of the NHS is to allow people to live healthy lives, in our own context. For Brogan, the big story in the NHS, nowhere hinted at in Berwick, is that it has conceived of its purpose from the wrong point of view: it is producer- rather than patient-centric, reducing patients to their conditions and then handing them out more or less standard medical packages – ‘push’ rather than ‘pull’. This is Fordist, industrialised, Model-T medicine – and the surface pressure and busyness conceals huge underlying waste and inefficiency. 
 
‘Almost every improvement effort I see in the NHS assumes that it has a single-loop problem to solve –  i.e. we are doing the right things, we just need to learn how to do them better’, says Brogan. ‘But the NHS has a double-loop problem – it is doing the wrong things. When you see people's demands in the context of the lives they want to lead, many of the condition-shaped interventions are simply the wrong thing to do. Making them safer is just doing the wrong thing righter’.
 
Thus it’s all very well to call for the NHS to become a learning organisation – who could disagree? – but it can’t do that unless it changes how it measures. Measures can be used either for learning or accountability and control but not both (the argument is here). Broadly speaking, NHS measures are related to activity, not purpose from the patient’s point of view: number of GP or A&E visits, for example, all of which are assumed to be demand needing to be managed, which is done by rationing the available resource to match. No learning is involved; the measures are used for control, not to learn how to improve patients' lives.
 
When measures are related to the purpose of enabling people to live healthy lives, on the other hand, the first discovery is that the more the organisation is ‘improved’ to increase throughput and cut costs, the worse it serves its patients. Take limiting GP appointments to 10 or even 8 minutes, or sometimes one problem at a time. This boosts throughput, but the price of failing to deal with the complete issue at first pass is multiplication of backed-up ‘failure demand’ as patients return for further consultations or present themselves at A&E instead. These pressures led to the setting up of first NHS Direct and now the disastrous 111 number – both unwitting factories for amplifying yet more repeat ‘demand’, the epitome of non-learning organisations. 
 
Vanguard’s figures suggest that up to a terrifying 85 per cent of all demand into the NHS is failure demand. While much of it is medically justifiable, it needn't and wouldn't happen if it were dealt with properly the first time round. This is the nightmare treadmill that the NHS has to get off and that is the essential subtext to Berwick – small print that is more urgent and alarming than the report’s headlines. This is why the influential Roy Lilley, broadly a Berwick admirer, describes it as ‘the most exasperating and annoying report I’ve ever read.’ While not going that far, and accepting that ‘it’s important not to lose the political will,’ Brogan also expresses his frustration: at some point, he says, ‘someone will have to get up and call a spade a spade’.
 

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User comments

Steven Henning Sieverts :: 12th Aug 13
Don Berwick wrote a much better report than the one he was asked to produce, but of course he had to stick to his remit. Simon quotes Brogan as saying that "we ended up with a safety problem because we weren't focused on purpose and value". That's just wrong, as well as reflecting limited understanding of DB's main message. One of DB's points (over many years) is that excellence in clinical care is always and inevitably a relative matter. No matter how focused the clinicians are on all of the right factors, there are always things that could have been done better, ranging from the diagnostic process through the treatment plan to the components of care. Minimising harm is no less important than any of the other components, and in many cases has the highest of priorities. The key is a constant focus on improvement, which also includes improving our clarity of purpose and value. A vital aspect is to do away with the culture of blame, trying to make things better by finding mistakes and punishing the pe
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