Changing the systems of care: we’re all in this together

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At the third and final lecture in our leadership series, Don Berwick reminded us of the shared challenges that providers and users of health care face. To preserve the legacy of a National Health Service for future generations we need to embrace change at all levels and acknowledge the challenges it presents.

One enabler would be for leaders at all levels to model their commitment to, and belief in, the NHS as a benchmark for global health to aspire to (Don did this every time he spoke about the NHS). We can also create communities in which we support each other to take some of the losses necessary to make system-level change; this will sometimes mean sacrificing our specialist interests, and sometimes making the case for changing models of work, for example, in integrated care.

Some communities are already moving in this direction. A number of quality improvement sciences, tools and techniques have been successfully pioneered in other industries and applied to health – such as the IHI methodology, which draws on a significant tradition of improvement based on Japanese Kaizen (meaning 'good change'). In our medical leadership programmes we have found that clinicians with an understanding of, and who are supported in developing ideas for, quality improvement value team-based working, which has  tangible benefits for both staff and patients.

Don offered a timely reminder, in the face of the Francis Inquiry, about the public's loss of trust in our clinicians and managers and about the resulting impact on the morale and motivation of our workforce. He stated on more than one occasion that 'people who give care can change the care' and challenged leaders in health to listen to their non-clinical and clinical colleagues who are providing care. In considering the opportunities for improving the quality of service; Don suggested that leaders needed to answer two critical questions: 'What do we need to change/improve?' And 'How should we go about this?'

One model that might help leaders to answer these questions is IHI's 'triple aim': improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care. By focusing energy and attention on population health and on wellness we can both improve the experience of care and take account of per capita cost. But to achieve this, we need to change our systems.

From a system point of view, organising care around patients’ needs will require professionals to work across existing boundaries – including the interface between health and social care, for which the need has never been greater. And we need to recognise and value the achievements of professionals who lead the way in change – with a special plea to politicians to have the wisdom to build on successful ideas as oppose to dismantling and changing things for the sake of political gain.

What can we learn from other health systems? Nuka in the Alaskan health care system offers a model in which the system was transformed from one focused on health care transactions to one focused on delivering health. To achieve this entailed significant change – to job roles, buildings, systems, objectives. It involved taking care out of secondary care hospitals and locating roles and responsibilities within the community. Above all it required the executive team to have powerful conversations, be visible and so lead the culture change necessary to recreate a more sustainable care system.

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Ghaleb El-Farouki

Comment date
15 May 2013
Thanks to the King's Fund for providing highlights and commentary on Dr Berwick's lecture; it would have been great to attend. Don Berwick aptly models the fundamental aims that successful leaders in health and policy should work for; the three highlighted aims actually feed off eachother. I believe that such a vision would translate into a genuine "health effort" as opposed to mere "healthcare", the latter describing a situation where we are solely putting out fires rather than simultaneously dealing with their cause. The British NHS is by no means a perfect system (if such a thing ever existed it would be quickly burdened with overwhelming demand), yet having experienced it myself as a health worker and user, I agree that the World could learn immensely from what it has achieved. No other service offers what it does while remaining free at the point of delivery. In a filmed documentary, the veteran Labour politician Tony Benn said something to the effect that the creation of the NHS liberated the ordinary citizen "from fear". I believe it is the true pride of Britain; yet its true potential and future lifeline lies in its heart-warming ability to recognise, admit and learn from pitfalls and, while keeping the patient at the centre of all its efforts, to change and evolve. If something or someone do not improve, then they are by definition falling behind, deteriorating.

Vijaya Nath

Assistant Director,
The King's Fund
Comment date
16 May 2013
Thank you , I agree that the challenge Don Berwick poses to us who work in, and have influence on the NHS requires us to think legacy.
What future are we leaving for future generations?We absolutely have to evolve.

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