To the moon and back: Don Berwick on politics, leadership and learning from NASA

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  • Posted:Thursday 30 May 2019

A podcast about big ideas in health and care. We talk with experts from The King’s Fund and beyond about the NHS, social care, and all things health policy and leadership. New episodes monthly.

What is it like working for Barack Obama and learning from NASA? What are the best and worst aspects of the NHS? Guest host Anna Charles sits down with Professor Don Berwick, President Emeritus at the Institute for Healthcare Improvement, to explore his career, the relationship between politics and health, and how to create joy in work.

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  • AC: Anna Charles
  • DB: Professor Don Berwick
AC:Hello, and welcome to The King’s Fund podcast, where we talk about the big issues and ideas in health and care. I’m Anna Charles, and I’m the Senior Policy Adviser to the Chief Executive here at The King’s Fund, and I’m going to be your guest host for this episode. And today I am thrilled to be welcoming back to The King’s Fund podcast Professor Don Berwick. Now Don last joined us on the podcast, to help celebrate the NHS’s 70th birthday, and is back today by popular demand, so that we can delve a bit deeper into his career and leadership journey. So, Don, welcome back to the podcast.
DB: Delighted to be here Anna, thank you.
AC:As an introduction, and for our listeners that didn’t hear your last appearance on our podcast, can you tell us a little bit about who you are and what you do?

Sure. I’m a paediatrician by training. I practiced for about 20 years. But during that period of time, I got very interested in quality of healthcare. I have training in public policy as well, I was on the faculty of the Harvard School of Public Health and the Harvard Medical School, and began to study quality in other industries. In colleagueship with other people, I started a non-profit organisation, way back in 1991, called the Institute for Healthcare Improvement, IHI. And although I continued to teach at Harvard Medical School, my main focus became setting up and then growing this non-profit effort to help healthcare around the world improve and that was a 20-year journey.

Then quite unexpectedly President Obama who had just been elected, asked me to come to Washington to run Medicare and Medicaid, the centres for Medicare and Medicaid services, which is our American public health insurance for elders and people of disadvantage. So, I went to Washington, and I spent a year and a half doing that. I came back to Massachusetts; I ran for governor briefly and that was a foray into politics. And then I returned back to the Institute for Healthcare Improvements. So, I’m there now as Senior Fellow and President Emeritus. I also work as an International Visiting Fellow here at The King’s Fund. So, I continue completely invested in improving the quality of care.

AC:Fantastic. And so, we’re going to be talking much more about your career journey, and your views on the big challenges in health and care. But we always like to start with a light-hearted question. So, first, your current roles, as we know, involve you travelling to health systems all around the world, including to the NHS. So, what’s the one thing you always have in your suitcase?
DB:A good book. I travel far too much. The advantage of being in an airplane is you actually get to read and think in ways that’s hard to do in the busy life when you’re on the ground.
AC:So, you’ve already given us a really fascinating insight into the sort of overview of your career journey? Can you tell us a bit more about that? How do you feel that you got to where you are today?

Not by a plan. Everything has been accidental. I think I had the good fortune of having good mentorship. A very important person in my life is named Dr Howard Hyatt who is a Dean at the Harvard School of Public Health and before that a Professor of Medicine at Harvard. And for some reason, he took an interest in my career and can’t overstate the value of mentorship, in my development. When I was a medical student, I also had an unusual advantage which was, the Harvard Medical School where I was, had formed a relationship with the John F Kennedy School of Government, and offered a joint degree programme, so, I could train as a medic, but also got a degree in public policy. That was really formative, and I think that helped me become… if I flatter myself, a systems thinker, thinking about the system as well as the work I’m doing.

Dr Hyatt had set up a unit at the Harvard School of Public Health which was called the Centre for Evaluation of Clinical Practices and that began my academic career. And so that, again, gave me a chance, even when I was seeing patients and acting as a clinician also to study the work. I was asked to oversee quality of care, the Health Maintenance Organisation, the HMO where I was seeing patients, and was frustrated by that, that assignment, and asked the Chief Executive - first I tried to quit, but the Chief Executive said, “Well don’t quit, why don’t you go look outside healthcare at the ways that complicated things get better? Maybe you can discover some things?” And that was an eye-opening journey.

I went to NASA, the National Aeronautics and Space Administration, and I was studying how they made things better. How did we get to the moon? How come electronic equipment works at such high levels of reliability? And I discovered science, the science no-one had taught me, and about how really complicated things can be made better with proper leadership and proper approach to improving processes.

AC:So, how far do you think then, in the time that has passed since you had that initial realisation around the science of improvement, how far do you think health services around the world have got, in terms of applying that systematically to the things that we do?

Well there has been progress, no doubt. I was not alone in this journey of discovery. The evolution of that thinking had definite phases, as I look back. The first phase was … I’ll call it the maverick phase. What happened was, dozens, maybe hundreds of people in the US and abroad were making the same discovery. And so, there was a very small, but very intense cadre of individuals who developed the theories and applied these theories from outside healthcare to healthcare. So, there was growth of knowledge, pivotally around the turn of the century around the 1990s, 2000s, a whole series of research reports appeared showing defect rates in healthcare. In the United States we had our National Academy of Medicine had two fundamentally important reports, one called To Err is Human in 1999 and one called Crossing the Quality Chasm in 2001. I helped write those reports. They were summaries of the data we had on things that went wrong in healthcare.

And it was pretty stunning. It was like, I don’t know, healthcare sort of woke up, and people said, “Wait a minute. We have these problems. We have patient safety issues, we have problems with reliability, problems with patient centredness, waste issues in healthcare.” And I do think now 20 years later, one can say that there’s plenty of knowledge in healthcare about the rates of problems. What we haven’t done yet really though is embraced the methods of change that I regard as scientifically sound. Healthcare still relies for complicated reasons on effort and heroism and exhortation and rewards and punishments as if somehow if we just yell loud enough, things would get better. That doesn’t work. We still have this journey ahead of learning the methods that do work in making them conventional, and it’s early days.

We have great examples of local application, I could list places that are doing good work, but no, we are still in adolescence with respect to methods of improvement.

AC:And how do you think your background as a clinician shapes the way that you think about the problems you see in the day to day work you do now?
DB:For me there was no substitute to actually being in the work of care. If I hadn’t been a clinician, if I hadn’t been seeing patients, I don’t think I would have developed a sense of understanding of what can go wrong, and how it goes wrong, and maybe the intensity of the feeling I have about it isn’t right when healthcare should be better. Also, in paediatrics and other medical disciplines, one is trained to think in systems terms. You’re seeing the child, but there’s a mother, and a grandmother and a father and a grandfather and siblings, you’re in the family system. And I loved being a doctor. So, I think that not losing touch with that.
AC:How do you not lose touch with that work?
DB:Well nowadays, unfortunately I had to stop practice already now fifteen years ago, and I miss it a lot. I just had too many other things going on. Working on improvement of systems, it’s good to keep your hand in the system, because it will teach you every day. You’ll get some humility and stories and a sense of what’s really important. Today, now that I no longer see patients, what I try to do is, when I’m visiting some places, go into the clinical unit, see what’s going on, talk with the frontline, and you stay in touch by being there. I tell executives, “If you’re in your office, you’re in the wrong place. You need to be out where the work is.”
AC:And you’ve got a fascinating outsider perspective on the NHS. You’ve been visiting the UK for many years now. So, if I were to really put you on the spot and ask you how the NHS compares to other health systems, what would you say are the best bits, and the worst bits, of the NHS?

I’m a big fan of the NHS. I’ve praised it in writing and in speaking. It’s one of the most ambitious human endeavours at national scale, focused on human wellbeing in the world. And it’s a thrilling concept that we’re going to have a universal system, free at the point of care, supported by general taxation. It’s a country’s devotion to healthcare as a human right, in a form that I really deeply honour. I think the strength of the primary care here, general practice, is the jewel in the crown of the NHS in my view. You developed early on a sense that people need a medical home, we call it, a place that they’re registered.

England has not cut short at all its investment in technology, and care people who are very seriously ill here with cancer or serious heart disease or complex illnesses, get a very … they’re lucky to be here, you have terrific high-end care as well. The strength of this system is enormous, and it will be even better as it evolves more and more toward integrated care at the locality level. And that, to me, is probably the biggest weakness I see, which is for reasons that are really weird, and I don’t understand them, even though the concept has been constant, of a system of care at the national level, centrally funded, when you go down to the locality level, you do discover here the same fragmentation that we deal with in many other countries, which is perplexing. You have a chance to think of care as a system.

But if I had to pick one thing that I wish had been better about the NHS, it was the ability to truly integrate care across boundaries at the locality level, a local level. The other thing I’ll say is, there has been a tendency here, more than in some other countries I see, to have a division between the management of care, the managerial forces, and the clinical forces. And even, I would say, some levels of disrespect among them, I don’t know what.

AC:On both sides?
DB:On both sides, yes. So, I think perhaps a little more lack of trust by clinicians in the management, but also management that doesn’t have a sound sense of the direct clinical care. That was evident to me when I first came here. It’s true in all countries but pretty obvious here. But that, I think is much better now. But in the end, you can only get excellence in a system with extremely high levels of co-operation and respect, right across the system, including between the people that are managing the people that are giving the care. I think it’s better now, but I think it’s something to keep working on.
AC:And back in 2016, when you were speaking at an event at The King’s Fund, you commented on the junior doctors’ dispute that was going on at that time. And you said that the government should apologise to junior doctors. Now I don’t know if you’re aware, but that caused quite a stir here. It was picked up in our national press. So, it’s three years on, since that dispute now. Do you think the lessons have been learnt from that episode when it comes to the relationship between government ministers and NHS staff?

Well first, remembering that comment, I think it was an ill-advised comment. I spoke hastily. What I meant was this. That I thought that the dialogue between the government and the junior doctors had deteriorated and someone had to take the first steps towards taking a deep breath and remembering we’re all in this together, and that the most important thing was the wellbeing of patients. And I thought the government would have been well advised to say let’s pause, and let’s take a breath, and find a better basis for dialogue. So, I didn’t mean to offend anyone, but I thought that it was very important to de-escalate. Things are better now, I think, or at least that episode is behind us. I’ll say this, on the positive side. I think among the resources the NHS has for continual improvement, few are as promising as the junior doctors. They see everything, they’re everywhere, they move around, they have tremendous knowledge, they have fresh eyes, a lot of energy, and they see what’s wrong, and they know what’s right.

And I think one of the great potentials here, that I would encourage leaders to take advantage of is to incorporate the insights and energies and contributions of junior doctors centrally, in the effort to design and redesign care. So, I would urge every leader to do that.

AC:Now one of my favourite phrases that you use a lot is creating joy in work. Can you explain a bit, what do you mean by that phrase?
DB:In some ways it’s sort of obvious that it’s impossible to imagine excellent caring given by people who don’t feel proud and joyous in their work. I feel deeply that proper care is nurturant, generous, buoyant, encouraging, embracing. And so, a workforce who is expected to have those properties has to feel buoyant and joyful and treat it with generosity, treat it with embrace. And so, I see no way to get excellent care other than when there is joy in work. It’s funny how many people find that naïve. I’ve been in meetings where people say, “What are you talking about? How can work be joyous? This is work.” And I say, “Wait a minute, this is also life, it’s your life.” So, it’s really, really important. It’s important, by the way, in all sectors, but in healthcare maybe most of all.
AC:So, where you’ve seen it, how is it created?

It’s leadership. It has to be a leader who values that or understands that, who has a basic sense of trust in the workforce, who is able to make himself or herself vulnerable and listen carefully, be nurturant. It starts at the top and with boards and governance also. Only they really have the opportunity to create the circumstances which people feel valued. One of my colleagues of the past is Paul O’Neill, former treasury secretary in the US, and he once said that a precondition for excellence is three things, that everybody at work can say, “I get treated with respect and dignity by everyone I encounter.”, “I am given the tools and resources to do the work that adds meaning to my life.” And the third is, “Somebody notices.” I just love that framing. And that’s how… if leaders are sure of those circumstances, it’s almost impossible not to be excellent.

I had the chance to try to walk that talk when I ran Medicare and Medicaid for President Obama, that was a big job, but it was in the context of vicious polarisation of the American political scene. The Affordable Care Act had been passed and we had this massive new law to implement against a lot of negativity. And I was asked to take over leadership of an organisation of 5500 people that had not had an executive for six years. It was really quite a difficult journey. When I arrived in Washington, I was remembering this advice from Paul O’Neill about dignity and respect. I knew that joy in work had to be one of the things we worked on. So, among the other things I began doing was trying to go to people every day, every way I could, to thank them, to tell them what they did was really valuable, to explain the importance of the mission, to emphasise teamwork. Because people just want to feel appreciated.

AC:So, in the context of clinical work, how can that environment be made so that people can feel that joy in work? So, for example, we had Professor Dame Sally Davies on a previous episode of this podcast. And she described some of the early experiences in her career as a clinician as brutalising. So, how can we get from that situation that Dame Sally Davies describes to the kind of supportive, appreciative culture that you’re setting out?

I think the attempt to nurture that culture is never ending, you’re never done. It’s not like if you tick these boxes it’s there, it’s every day work. A couple of hints for developing that culture, the first is meaning in work. You get the chance to have a positive culture of work when people are connected to the meaning of their work, which means leaders need to invite and support constant conversation about the importance of what we do. And in healthcare, that should be the easiest job of all, because what we do is so inspiring, it’s so important to people. A second is a sense of teamwork which is, we are in this together. And the unfortunate tendency in healthcare to say, “It all depends on the hero”, you know? The doctor is the captain of the ship, whatever, no, no, no, we’re in this together. And that patient who has come to us, to help relieve their suffering, expects us to do it together.

And I think leadership that emphasises that interdependence is really crucial, which means, by the way, the leader has to act as though he or she understands that and honour interdependents themselves with humility and a sense of connection. Another thing that really helps is the voice of the people we’re helping, the patient, the family, the carer, in the room with us all the time, where we’re saying, “How are we doing? Tell us how we’re doing? What’s it like through your eyes?” That will encourage civility and a sense of teamwork and interdependence and it adds joy to work. There is a sharp edge to this, I must say, which is to be intolerant of those very few people who, for whatever reasons, in their background or their personality or illness, cannot be civil, have trouble being co-operative. They need to change or leave. And there is a certain test that leaders have here about when that occasional thing happens where someone is simply not able to encourage others and be respectful that they need to change or leave.

AC:And working in organisations like the NHS where teams can be very transient, how can that sense of a team be created, when it’s not a stable team?

First recognise the problem so that when a new junior arrives at an institution and is going to be there for a while, the orientation and the welcome and the sense of values that they’re going to feel, is absolutely crucial. So, you have to understand the risks of that transience. Another answer is to reduce the transience, that stable teams matter. But you know, it really is all about values. If the values are clear, then the new arrival will sense it, if they’re unclear, the new arrival will sense that. When I took over at CMS in the Obama administration, I brought along a set of values that we had nurtured at The Institute for Healthcare Improvement, IHI, five in particular. And these became the centre of my work. Not a nice thing to do when everything else is done, but at the beginning, the five values, they’re operating values.

They’re like what it’s like to be here, and that I espoused were boundarylessness that breakdown all of the walls between us. The speed and agility. We have to move fast because the world is changing fast, and the needs are there. Unconditional teamwork, which is a habit of sharing and generosity. Innovation, which meant welcoming change, not fearing it. And then customer focus, which is listening to the people we’re helping all the time. We are the servants, they are the masters, and we need to understand that and listen to them. So, those five values. These weren’t just words. What I tried to do was incorporate them into everything we did. I linked it to personnel reviews, I used it in speeches. Because I feel that when the values are clear, the rest happens. Strategy is easy when values are clear, strategy is impossible when values are not. That will help with this joy in work, and it will help with transience.

AC:And when you were leading the centres for Medicare and Medicaid services, you were then working for another great leader, President Barack Obama, so, what was it like to work for him, with him, with his team?
DB:Mission was so compelling. This was a courageous president who had done what no president had been able to do for 50 years which was to begin to move America again toward healthcare as a human right. It was very inspiring to have a leader who was able to connect our work to mission at that level.
AC:And at the same time, there were a lot of wider politics going on around what you were doing. How did you deal with that? First describe a bit what was going on, and then how you dealt with that?

Vicious politics. America had never been so divided, since unfortunately we’ve become even more divided. But this president had come in, who was our first black president, and I do think there was an undercurrent of racism that was not explicit, but one could feel that there were people who were having a lot of trouble taking… that our country took that very important step. He was a person deeply committed to a spirit of generosity and public service and social support, in every field. And there are strong political forces in the country, of the United States, that have a different view, whatever the reason, whether it was racism, or political doctrine, polarisation was phenomenal and healthcare was ground zero, because President Obama picked healthcare as his legacy, as his flagship effort.

He could have picked environment, he could have picked education, he picked healthcare. So, he kind of declared that as the battlefield. So, my work was being conducted in a very highly contested arena. It was interesting, and I learned a lot. My own way of dealing with it, whether it’s a lesson for anyone else or not, I don’t know, was that I could not change the political discourse, that wasn’t within my gift. What I could do was lead the agency, was actually take this organisation, and build it as a learning organisation with buoyancy, with a sense of pride, and with deep commitment to mission. Work every day on texture of healthcare in America, focus in, not out, and deal with the politics as the rain. I needed an umbrella, that’s all. And that was my view, listen and then how about we go back to work now?

AC:And so, in general, what is your take on the relationship between politics and healthcare? Can that relationship ever be a helpful one, or does the politics really always get in the way?

Look healthcare is something people deeply, deeply care about. And it absorbs a lot of our economies in my country, it’s 18% of our economy. Here less, but still very important. Of course, healthcare is going to be political, it had better be, because we’re affecting people’s lives. A mature view is to accept that, remember you’re there for the patient, and for the public’s health, and every day show up for that and let that be attractive so that the politics eventually have to defer to that. I actually somewhat prefer the way it is in the UK, not because it’s easier, it’s harder, but because you have an arena, a public arena for decision-making that we don’t have in the US.

You can’t get people in a room in the US and say, “Well what is our policy towards universal healthcare?” Or what you’ve done for example with the five year forward view, and now the long-term plan, for the NHS, is a very mature national political dialogue, about what we want our healthcare system to be. And I think it’s a tremendous opportunity, not easy, but it’s what needs to happen.

AC:And thinking again about healthcare in the US, you once described Universal Coverage in the US as the holy grail for the health system. Do you think now you’ll ever get to that?
DB:We will get to it, eventually we will get to it. I will, I hope, in my lifetime, but if not sometime soon for my children and grandchildren. It’s one of the major embarrassments in America that we don’t have healthcare as a human right yet whereas every other western democracy does. I feel constantly apologetic about that. We’re making progress. The Affordable Care Act added coverage for about 20 million people. We still have about 28 or 30 million that don’t have coverage. But I think we’ll get there. Our problem is partly that we seem so thoroughly committed to using private sector mechanisms to achieve universal coverage, and I think we’re discovering the limits of that approach. And so, I’ve become a fan of expansion of public sector insurance and coverage. And I think we’ll get there. It still … it will be a while.
AC:It’s interesting, because we obviously have the benefit of Universal Coverage under the NHS, but we don’t have that for social care. And actually, it’s proving politically really difficult to move on from that, creating that change is so difficult.
DB:Yes. You asked me earlier about shortcomings in the NHS. I should have listed that as a big one. You’re not alone. But look, the science is absolutely clear. The causes of health are not healthcare. The causes of health and illness lie outside the healthcare system in what are called social determinants and they’re very, very powerful. So, if you really want a healthy society, you’ve got to work on the things that make people sick. They lie in the experiences of early childhood, in birthing, they lie in the education system, and it lies in infrastructures like housing and transport, and it lies in a fundamental sense of fairness and equity. An inequitable society cannot be a healthy one.
AC:So, now I want to ask you a bit more about your experiences as a leader. And if you could go back now to the start of your career, and give your 20-year-old self, just one piece of advice, what would you say?
DB:You don’t have to have all the answers. The more I grew and matured, I think the more aware I was that the demand, bearing the burden of having to have the answer, it’s wrong. It’s not leadership, it’s the opposite of leadership. Leadership is building up the confidence of others and having humility to benefit from the great wisdom of others around you. And so, I guess I would have… I was like many young professionals, I thought I had to learn it all and know it, you don’t.
AC:Can you think of a time when you’ve really had your mind changed, where you’ve really switched your position on something?

Yes. Two episodes occur to me, one professional, one personal. When I began the journey that shaped my career and quality, began outside healthcare. My then employer, one of the very first contacts I made was with NASA, the National Aeronautics and Space Administration. I cold called it, I said, “Could I speak to the person that does quality?” And I got him on the phone, his name was Guy Cohen. I said, “I’m from healthcare and you got to the moon, and can you help me understand how you did that, that sounds very hard?” And Guy Cohen, who didn’t know me from Adam, said, “When can I come and see you?” That was his response. He was the Head of Quality for NASA, quality and safety. I said, “How about this week?” And within a day or two he was up in my office.

And I remember the day, it was a transformational day for me, because he walked me through NASA’s systems for excellence, and it was one of the most transformational days of my life. It would take me another podcast to explain what he did. But what I saw was complete devotion to excellence as a system, with an infinite respect for the workforce. He said to me at one point, “Let’s say that in a hospital, a nurse makes an error, and a patient gets injured, what would happen?” I said, “Well there’d be an incident report file, the nurse would be put on suspension, probation maybe. She might be fired.” He said, “Well then you’ll never be safe.” He said, “That person has the most valuable knowledge in the entire organisation about something that could go wrong. And they need to be honoured and welcomed and embraced, because now they’re a tremendous help to you.”

And he told me about trips that they would take to subcontractors, seventh order subcontractors, in some small town in the Mid-West who’s making a little piece of metal that’s going to go in a rocket. And he would say they would travel there, and they’d say, “You’re making this little device, and that’s going to go in this machine, which is going to go in this device, it will go in that device, it will go in a rocket, and there’ll be a human being sitting on that rocket, and their life depends on what you do.” And this whole idea of meaning and purpose. It was an amazing time, and I saw what was possible.

The other transformational experience for me was, illness in my own family. My wife became extremely ill, almost died, and I was already… I was deeply in my career, but for months I was at her bedside, watching the care, and seeing things go wrong. And I already knew the technical stuff, I knew about improvement, I knew about processes, I knew about safety issues, but experiencing them was different for me, and I guess it radicalised me, it gave me a whole new sense of energy and intensity. And that was an unfortunate way to be changed, but it changed me.

AC:Now we invited some of our podcast listeners to send their questions in for you via Twitter. And we had a really interesting question from Dr Nick Mann. So, he wanted to know, in relation to the work you carried out in 2013, reviewing patient safety in the NHS for David Cameron, in the wake of the publication of The Francis Report, into the breakdown of care at Mid-Staffordshire Hospitals, Dr Nick Mann wanted us to ask you what you think the passage of time has demonstrated regarding the government’s pledges back then to honour the report’s recommendations?

There has been progress. The bad news, and I’ll start with that was, in leadership, in general, government in particular, there is a tendency to have one’s attention drawn to drama, egregious fault and the creation of consequence is punishments. And there was a tiny, tiny piece of that report that did speak about very, very egregious sabotage behaviours, and said that we can’t tolerate them. Unfortunately, that became headline. It was like press pulled this one little point out, and made it a headline, when that wasn’t the headline at all. The headline was quite the opposite. But government is constantly seduced into this kind of reprisal activity. You saw it in the very, very unfortunate Bawa-Garba case where terrible mistakes were made in managing that case, hopefully since redressed. So, there’s backsliding.

On the other hand, I’ve seen deep investments in this country here on building the learning capabilities, that report was really about. I think you’ve matured way beyond the simply reporting systems you used to have, and there’s a lot of energy now around patient safety through the academic health science networks. I see in the five year forward view that’s a quality document, that is a document focused on aims and goals and respect, and I think the long-term plan is even better. The long-term plan has some very important concepts around building capability and joy in the workforce. So, I do think there’s progress. It’s always hard, and the seduction of blame is always there. Blame never helps, but it’s highly seductive and we need to keep fighting that.

AC:And one final question, you’ve had a very long and distinguished career, as we’ve heard, and you’ve run organisations, you’ve advised governments, but you still work really, really hard. So, what is it that drives you to keep working, when you’ve already achieved so much?
DB:So much is not yet done. I don’t think I’ve achieved as much as I wished. The face is the patients, you know? We all know people, and they deserve better. For me also, the global scene matters. I think we are a deeply unfair planet, poverty and disadvantage and exclusion, inequity are still everywhere and really getting worse, and I can’t stand it, I think it’s really wrong. And so, I see the journey of quality as a journey toward fairness. And I don’t want to stop.
AC:So, you’re not going to stop just yet?
DB:No plans to stop.
AC:Well thank you so much Professor Don Berwick, for joining us again on the podcast. That’s it from us. You can find the show notes for this episode and all our previous episodes at Thanks for listening, and thanks as always to our podcast team and our producers Ian Ford and Sarah Murphy. If you enjoyed this episode, please subscribe, rate and review us on iTunes. And if you have feedback or ideas for topics that you would like to hear covered in future episodes, then get in touch, either on Twitter at The King’s Fund, or on my account at @annacharleskf. We hope you can join us next time.


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