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Parsing the Berwick Report on the British National Health Service

Posted by John McDonough  August 25, 2013 04:07 PM

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It received only scant notice in the U.S., and in Massachusetts, but earlier this month, a British commission formed to recommend improvements to the quality of medical care in the United Kingdom issued its final report.  Why should anyone care on this side of the pond? Several reasons:

The commission was chaired by Dr. Donald Berwick, MD, current candidate for Governor of Berwick.jpgMassachusetts, former Acting Director of the U.S. Centers for Medicare and Medicaid Services (CMS), founder of the Cambridge-based Institute for Healthcare Improvement (IHI) and an internationally recognized expert on improving the quality and safety of medical care. Berwick took the (unpaid) chair job at the personal request of British Prime Minister David Cameron, following a quality of care scandal at Mid-Staffordshire Hospital that has shocked the British public. (Pictured: Berwick with US Health & Human Services Secretary Kathleen Sebelius.)

Americans have a thing about the British National Health Service (NHS) that is called love/hate -- even more intense than our feelings about the Canadian socialized health insurance system.  Every NHS development is grist for the never-ending U.S. debate over the role of markets versus government in health policy.

For those who see the NHS as the world's leading example of life-threatening health care rationing (including, it would seem, every Republican member of the United States Congress), the Mid-Staf scandal is exhibit A for the follies and tragedy of government-run health care. Even for those who admire and respect the NHS, the scandal demands attention and accountability; the Brit's value of equitable and universal health care cannot excuse this major failing.

And because Donald Berwick is now campaigning to become Massachusetts' next governor in January 2015, this report will be dissected by his rivals -- should his candidacy become a serious threat. (I wrote an appreciation of Berwick's role in health care and in DC when he left CMS in late 2011.)

So the Report compelling from varied perspectives. (WBUR's Martha Bebinger did an informative interview with Berwick about the report earlier this month.)  Let's dig in more deeply to see what's interesting.

First, if anyone expected that Berwick would use this situation to distance himself from the NHS, they will be surprised. If anything, he doubles down for the NHS. Report:

"At its core, the NHS remains a world-leading example of commitment to health and health care as a human right -- the endeavor of a whole society to ensure that all people in their time of need are supported, cared for, and healed. It is a fine institution. ... We have the data. Waiting times are shorter than 15 years ago, cardiovascular care and outcomes are far better, cancer care is improving fast, and healthcare-acquired infections rates have plummeted. Stroke care in London reached world-class levels."

In his time in DC at CMS, Berwick was regularly poked by Republicans for his complimentary statements about the NHS (perhaps as close to "Mordor" as many of them can imagine). Even worse, in 2005 he was named an Honorary Knight Commander of the Most Excellent Order of the British Empire by the Queen of England for his contributions to improving health care quality in the United Kingdom. One doesn't have to be a political ad designer to sense the possibilities. Certainly, we might be in for a gubernatorial campaign with a more global flair than we have ever before experienced.

Just as much as some will loath the Berwick-NHS connection, others will be drawn to it. Who knows, the attention might trigger an intelligent conversation about the relative merits and demerits of both systems. That's a conversation worth having, though perhaps not for a candidate seeking to be the king of Beacon Hill.

Second, the Berwick Report stands in contrast to the above-mentioned Francis Report which had an extensive list of 290 recommendations for improvements at all levels of the system. Berwick's Committee, which included Lucian Leape from the Harvard School of Public Health and Maureen Bisognano from IHI, was charged "to distil for government and the NHS the lessons learned, and to specific the changes that are needed."

Here are the headline conclusions:

1. Patient safety problems exist throughout the NHS.
2. NHS staff are not to blame.
3. Incorrect priorities do damage.
4. Warning signals abounded and were not heeded.
5. Responsibility is diffused and therefore not clearly owned.
6. Improvement requires a system of support.
7. Fear is toxic to both safety and improvement.

As far back as the late 1980s, Berwick has held that the medical care's then-obsession with rooting out "bad apples" was the antithesis of fixing health care and continuous quality improvement (CQI). The problem, he believed, is almost always about bad systems, not bad people. More than 22 years later, that cornerstone belief resonates throughout the new NHS document into all seven conclusions, especially numbers 2 and 7.

That "systems first" ethic is now widely embraced throughout the U.S. health sector, even if at times poorly observed. This view, though, is more counter-cultural on Beacon Hill and in the state's media that love to report on the dogs chasing the fox (i.e.: Ms. Annie Dookhan). Former Commissioner of the Massachusetts Department of Social Services Harry Spence exemplified this view during his tenure when he regularly stood up to accept responsibility for agency mishaps, rather than blaming underlings.  One can only wonder how this stance will fare on the campaign trail and how it might fare in a Berwick Administration.

Finally, let's look at the 10 key recommendations:

1. Overarching: The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.

2. Leadership: All leaders concerned with NHS healthcare -- political, regulatory, governance, executive, clinical, and advocacy -- should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement, and support.

3. Patient & Public Involvement: Patients and their carers should be present, powerful, and involved in all levels of healthcare organizations from wards to the boards of Trusts.

4. Staff: Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS's needs now and in the future. Healthcare organizations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported.

5. Training and Capacity Building:
a. Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives.
b. The NHS should become a learning organization. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS.

6. Measurement and transparency:
a. Transparency should be complete, timely and unequivocal. All non-personal data on quality and safety, whether assembled by government, organizations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.
b. All organizations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.

7. Structures and Regulation: Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.

8. Enforcement: We support responsive regulation of organisations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.

One thing Massachusetts shares with the U.K. is a controversy over whether nurse staff levels in hospitals should be mandated by law. The fracas -- between the MA Nursing Association and the MA Hospital Association -- has been going on here since 1994(!) without resolution. In fact, the MNA is now getting ready to bring mandated staff levels forward as a Massachusetts ballot initiative on November 4 2014 -- the same day as the next gubernatorial election.

The Berwick Report stops short of recommending ratios by law, and instead recommends that the British National Institute for Health and Care Excellence (NICE) "undertake as soon as possible to develop and promulgate guidance based on science and data." That may work in Britain, but in Massachusetts, gubernatorial candidates are going to have to pick sides, and it will be interesting to see how Berwick will play this zero-sum game of power politics.

The playing field for the Massachusetts gubernatorial election is still forming. It seems that 2010 Republican nominee Charlie Baker will come back for a second try, and without a primary opponent. The Democratic field is diverse: Berwick, Treasurer Steve Grossman, State Senator Dan Wolf (campaign on hold while his Cape Air conflict gets processed), health care executive Joe Avellone, and homeland security expect Juliette Kayyem; Attorney General Martha Coakley is expected to join in September, and we're still waiting to see if Cong. Mike Capuano and/or Somerville Mayor Joe Curtatone will jump.

It's a formidable and curious field that draws this diverse collection, leaving room for lots of engaging policy dialogue and conversation. Maybe the Berwick Report will not matter a whit. If Berwick's campaign gets traction, it may become relevant or not.  Perhaps we might even have a whiff of serious conversation about the relative merits of Massachusetts vs. British health care.

I'm game for that!

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »

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