Don Berwick: Quality improvement in the NHS

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Speaking at our breakfast event on 23 February 2016, Don Berwick gives his views on The King's Fund's report, Improving quality in the NHS, and discusses what the NHS can learn from other countries.

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Thank you for the chance to spend this time with you. This is a platform that’s getting increasingly familiar to me happily thanks to Chris’ generosity and The King's Fund for hosting me as International Visiting Fellow.

I will, as Chris said, just try to set the stage. I’ll be as brief as I possibly can be, leaving most of the wisdom to emerge during our conversation.

It’s tough times. I know it, even across the Atlantic I can feel it, let alone when I’m here. You’re dealing with a highly conflictual environment right now in the English NHS with a demoralised workforce and especially demoralisation among your future workforce which is a sign of enormous distress, it is not a formula for success in this country to be in conflict with the people that will make up the workforce of the future.

The pressures on production are unprecedented and it is very clear performance is in jeopardy and in fact there are early signals of deterioration that cause those of us who are great fans of the NHS to be concerned. And as one reads the papers and studies what’s going on I’d say this is a time of negative discourse and for someone who has as much admiration for the National Health Service as I do, it’s a troubling time to watch.

Remember the greatness of what you have. It would be possible to spend all the time Chris has given me just reciting some of the enormous achievements of this sector of healthcare in the world. Great Ormond Street, The Royal Marsden changing the fate of cancer victims and children with heart disease in my own experience, giants Archie Cochrane and Austin Bradford Hill, Richard Dahl, changing the way we think about disease and its sources, the foundations of epidemiology sit in this country and in the system, recent work by Michael Marmot, and your own commitment as a nation to equity and justice and the delivery of healthcare sets the international standard. You are holders of an enormously important trust for the world and one hopes not just for England but for the rest of the world that you emerge from this with a stronger NHS even than you have.

Now we know what to do, what to accomplish. The Institution for Health Care Improvement, where I’m now a senior fellow, articulated in 2006 and 2007 the triple aim, better care, better health and lower cost. Better care so that people who are in care can experience safe, effective patient standard, timely efficient equitable care, the goals that we now know internationally should be characteristics of performance in healthcare systems. Even though we don’t have that performance in any known healthcare system in the world there are many, many bright spots and we know a lot about how to make the care better.

We know even more about how to make the health better and indeed if I go back to the work that I just told you about and I have to again credit Sir Michael Marmot’s recent writings especially we know a lot about how to make populations healthier and we also know how to do that at continually lower per capita cost. We understand globally now the nature of waste, of non-value added activity in healthcare and the margins for gain are enormous. In my country we estimate out of the three trillion dollars we’re putting into healthcare one trillion is pure waste. Better care, better health and lower cost. No question that that’s the destination.

And we know a lot about to get there. A little bit of quality lecturing I’m going to do at the moment refers back to the work of Dr Joseph Duran, one of the great quality scholars of the past century. Duran tried to articulate the content of a total approach to improvement, total approach to quality and he reminds us that there are basically generally three enterprises under way in anything you’re trying to make better, this would be your marriage, your knitting, your garden or your healthcare. There are always three things going on.

Control, that’s fixing a flat tyre in your car when the tyre goes flat. Your tyre isn’t usually flat but you have to fix it when it’s out of control. Then there’s improvement which is the great vast enterprise most of us are engaged in most of the time with anything we love, we’re trying to do things better all the time, trying to make your gardening better, your soufflé better or your marriage better and you’re doing that with constantly learning and enquiring.

And then there’s a bit reserved for invention, totally new ways to do things, moving from cars to aeroplanes and changing the approach completely. Duran’s trilogy is canonical in the field I'm from, quality management, and in any mature quality environment all three are under way at the same time.

In approximately proportion shown most of us most of the time in a health environment are just trying to get belter every day. Fixing the tyre when it goes flat and inventing things and most of the time just trying to learn and get better. We know what the system that has to emerge needs to look like. Many formulations are possible, this is one pulled out of an old slide file I have. We need to move from fragmentation to unification and that begins with unified budgets.

England has the enormous advantage of a unified budget, at least at the top. You’re way ahead of other countries in the possibility of actually beginning to think as a system.

Moving away from the hospital as the centre of a system, the hospital shouldn’t be the centre of healthcare, it’s a repair facility, it’s not the source of health. Home is the source of health. Moving from how I was trained as a doctor to be a heroic soloist to thinking in terms of teams and interactions and now in the modern information age instead of moving people to visits and admissions, moving care to the people by moving knowledge to them.

My successor CEO at the Institute of Healthcare Maureen Bisognano has over and over repeated another refraining from dealing with the people we help with the question what’s the matter with you to the question what matters to you? That’s what patient centred care really looks like, and done with a sense of co-production and co-design with the very people we help, we’re in this together. And finally moving from a sense of scarcity, always needing more to a sense of abundance as one looks around to the health generating features of communities. We know where we need to go.

The question is how? There is a distinctive difference between the Duran trilogy in which the fundamental investments are in learning and getting things better to a system that feels a little bit like this, in my country and in yours. Go out to the workforce, speak to the doctors and nurses, speak to the managers and executives and ask them what it’s like. Is the general enterprise one of continuous learning in improvement and exchange, with a modicum reserve for invention and a modicum reserve for fixing flat tyres? And they say no. It feels like all we’re doing is control. And this isn’t even control as Duran intended it, this is external control, this is surveillance, scrutiny for rewards and punishments, carrots and sticks, it is not the formula for reinvention of a new care system, you cannot get this system from this distribution of effort.

Instead what you get is fear. And I’ve shown this in this room many times, it’s the cycle of fear described in the 1950s in other industries as they were abandoning reliance on inspection to improve because of what it does to a workforce. When inspectors show up constantly discovering if you are wrong, if you are deficient, if you need fixing. What happens is the workforce responds with fear and hiding, they shoot back at the messenger, no-one in quality assurance is beloved, CQC, do you invite them to dinner? The information gets filtered then by the workforce, they’ll always get control of information, if you want to see that study the Mid Staffordshire story.

And then that gets internalised in the management system and this cycle, this erosive cycle is well described in other industries but industries that learn to move from inspection to improvement is the mainstay.

So what can we do about it? Move from inspection to improvement. Move from surveillance and contingency and reward and punishment, remove from asking people to try harder to asking people how we can help them to learn. I think this is at the heart of the report that is being launched today, Improving Quality in the English NHS that Chris and Jennifer and I wrote.

I want to first express my delight that The King's Fund and the Health Foundation are working together on this, and also to give you a heads up that later on in the late spring or early summer you’ll be seeing really a kind of sister report from the Health Foundation itself written by Professor Sheila Leatherman digging a little deeper into how the parts of the NHS can work better to support improvement.

And what I want to do is show you in a few minutes what the elements of the strategy that we laid out were. I don’t think Chris or Jennifer or I believe this is exactly right, it’s a first draft, and I'm going to be commenting on this from my personal point of view and I'm not speaking for Chris or Jennifer and I hope they’ll correct me when I make errors in terms of what they intended in terms of the publication, but we’re laying out ten principles, ten elements of the strategy.

The first is to enable local activity. Improvement is a local phenomenon. Even though common knowledge can be crucial it will emerge as a characteristic of the individual hospitals and trusts and clinics and local organisations and the NHS that improves will be one in which the in-house capacity and local environments for continuous quality improvement is robust. That does not mean that everyone does it alone, because the second great idea behind continuous learning is to learn from each other. IHI has the phrase ‘All teach all learn’. A supporting NHS organisations that allow shared learning and regional support to make it possible that when you’re patch invents something, your patch can discover it as easily as possible. David Fillingham’s leadership in the North and his prior work with the Modernisation Agency shows what collaborative improvement really can look like when there are mechanisms for shared support.

We believe that there needs to be in this country some modestly sized national centre to support that kind of activity, with the demise of the strategic health authorities the country has lost an infrastructure at the regional level for supporting the kind of collaborative learning that item two refers to.

There needs to be some national support for allowing learning and improvement to occur. Now CQC in my opinion can be a part of that because CQC is a treasury of information on the basis of which learning can occur and there’s implied in this to me a role for CQC as a supplier of knowledge and information to the very system that it’s also scrutinising.

None of this happens without leadership. The Duran trilogy requires an executive function that understands that proportionate and contained activities within the jobs of control improvement and invention and innovation. And so the development of leadership is crucial here and the development of leadership in the way that Chris and Jennifer and I are writing about is leadership developed to support the improvement of the system, so that there’s not a separate function for development executive talent clinical and non-clinical executive talent but it’s joined up with the idea of improvement at the centre.

The other requirement at the leadership level are the national bodies that exist to help the NHS become the new NHS. They need to do this together, absolutely hand in glove. The key in NHS England, NHS Improvement and CQC are just the beginning. We strongly believe there needs to be a single unified coordinated strategy among these entities so that they’re essentially owning their portion of a shared plan which each of them would describe exactly the same if you stopped them.

The sixth idea is to do the reinvention in concert with the clinical and non-clinical leaders in the National Health Service. This is not something done to the health service in which ideas are generated at some smart centre and then passed out to executives to implement, it’s not the way we’re talking about. Modern improvement involves collaborative shared discovery and it is the clinical leaders and the leaders of the NHS organisations who can best develop the strategy. I will editorialise about the junior doctors if I may for a minute. The most important future for a relationship between this system and the junior doctors is to help the junior doctors help the system reinvent itself. This is a reservoir of talent and knowledge and energy that could be harnessed as a contributor to the pursuit of the triple aim where the five year full review which is really the triple aim in English.

The seventh idea is the other partner beyond the workforce itself and that is the patients. The new care system is one that is co-designed with the patients’ communities and carers who are getting the help. They have better ideas than the people providing care of that care should look like. It’s listening to and incorporating the voice of the people served everywhere in all phases of design and when I go out to visit a trust in this country or one of the new vanguards, one of my key pieces of advices is get the patients’ families, carers, community in the room, regard them not as tokens, not as people who are giving you input but as absolute partners in the design and re-design of the system of care. That’s especially true as the system reaches, as it has to do, to health and social care. Not invented here, we use that phrase in the United States, the not invented here syndrome, if I haven’t done it it doesn’t exist. Forget it. There are in this nation and other nations examples of successful that I’ll show you in a moment that you can use and draw upon, you have them right here in this room, what goes on at Salford Royal or what’s gone on in Northumbria, at East London Foundation Trust, these are examples of success that should become absolute objects of study and learning for those of you that want to be as successful as those organisations.

And there’s a great reservoir of talent outside the NHS itself what can be pulled in. I’ll mention of course the foundations, The King's Fund and the Health Foundation in Nuffield, but think even more broadly than that, there are people all over this nation that want to help you re-invent the National Health Service. Will you get this right the first time? Of course not, of course not. Continuous improvement is continuous learning which means the constant cycle of reflection and consideration about how we’re doing is really crucial.

And so the tenth item here is that we’re not going to get it right the first time and there has to be a self-scrutiny involved here as we try to navigate to the new system. I will say here again this is editorial, it’s not Chris and Jennifer’s view unless they want to own it also. The government must reflection the effects of austerity, on the ability of the National Health Service to survive and thrive. I know no nation that is seeking to provide healthcare at the level that western democracies can at 8% of GDP let alone 7% or 6.7% that may be impossible and it’s very crucial that your government reflect on whether it is overshot on austerity.

Can you do it? Absolutely you can do it. Every item in this strategy already exists in the UK, in fact exists present and in your history and I want to mention a couple of quick historical examples. One of the great achievements in the world of quality improvement goes back to the work of Sir John Oldham at the turn of this century when he was asked by Tony Blair to undertake the enterprise of making primary care access improve as well as ischemic heart disease care and especially relations improve. What John did at a national scale, it was the largest improvement effort in history and you did it in this country, you did it with every one of the principles that I just showed you on that map. This shows the success of the primary care development teams, the improvement of access, wave on wave on wave, as eventually he reached almost 50 million people in England with better primary care access, learning as you went, in a collaborative improvement involving the workforce, using scientific principles in a buoyant and encouraging way.

It’s happened again now in East London Foundation Trust, in a very difficult patch, a poor area in the mental health world which is extremely difficult to work in, we’re seeing regularised improvement now at that Trust with increasingly, vastly increasing staff morale. The idea that improvement creates joy and work is not a theory, it’s evidenced in the work of places like East London Foundation Trust.

You have neighbours here, Scotland is probably having more success than any nation that I know in the world at the moment, improvement at national scale for five million people not 50, but Scotland should be studied by England. NHS Scotland is making enormous progress and I think it would be good for you to reach outside your own borders to study what’s happening, this is improvements in Scottish mortality at 23% in a six year period.

And then there’s the technology development which I think you’re seeing in leading forms here in England right down the street at Paddington and at St Mary’s Hospital you have this group of young ophthalmologists working with telemedicine for ophthalmology care. This is a man who is being scanned and read I believe in Pakistan and the image quality is better than in a machine at St Mary’s. This is screening of children for visual acuity in Kenya by the same group, the Peek Group at St Mary’s screening 10,000 kids in Kenya for visual acuity using cell phones. The ability to begin to think in a totally new way about design, it’s right here, it’s down the street, it’s in this country and you can learn from each other.

The last comment I’ll make is about the workforce. I know how hard it sounds right now, it may even sound naïve to you, but I agree with W Edwards Deming there is no route to excellence other than through joy and work. You can't exhort, beat, incent a workforce to achieve excellence. You can achieve compliance but not excellence.

The NHS is an organisation that deserves to be joyous in its work. You have a country that values the NHS above any other institution in your nation. The idea that working in the NHS should be anything less than a source of continuous pleasure and development altogether on the same page is one that is within your reach.

Maureen Bisognano again my successor at IHI puts it this way, you cannot give what you cannot have. And so of the goals needed for this nation in pursuit of the excellent healthcare you need to be showing the nation, one of them has to be to restore a level of trust and joy in work that I think is accessible, it’s accessible through improvement though and that’s what our paper’s about.

I think I’ll stop there Chris, thank you very much.


Margaret Georgiadou

Retired Senior Lecturer,
Comment date
24 November 2016
We already have an excellent NHS but it has been deliberately underfunded year on year. We have the lowest healthcare investment in the EU. The staff I encounter in the NHS are 'joyous' in their work, and provide a remarkably excellent service despite the non-'joyous' underfunding. I recognise that the country is bankrupt. I do not recognise that that is the fault of of a wastrel NHS.

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