the hsj interview: Don Berwick

Published: 10/04/2003, Volume II3, No. 5850 Page 20 21

Despite hailing from the US, a nation famed for slick corporate efficiency, Dr Don Berwick is impressed by the NHS's sense of leadership and the speed at which improvement can be achieved. He even likes the fact that politics is involved. So, considering the head of the Institute for Healthcare Improvement's ideas are so influential in Labour's bid to modernise the service, what does he think of the show so far?

It is not that surprising that Dr Don Berwick speaks of the NHS in glowing terms. As a champion of more efficient and system-based medicine through his Institute for Healthcare Improvement, he has seen the UK adopt, adapt and implement many of this theories. Until recently, he was a member of the NHS modernisation board and remains the architect of much of what the Modernisation Agency itself is trying to achieve.

Speaking at his Boston offices, IHI's president and chief executive officer is quick to say how much he values UK healthcare and what it is trying to achieve: 'It takes my breath away. I can't believe you are going so fast. There are still plenty of challenges, but the progress is incredible.'

Drawing a contrast with the multiple healthcare networks in his native US, Dr Berwick even admits to being envious of the NHS, partly because of the universality principle on which it is founded: 'It is a continuous source of frustration and some embarrassment to me that when I come to the UK, I come to a country that says: 'You will have healthcare.'And when I am in the US, I am in a country that has not said that.'

The structure of the NHS has also long caught his attention: 'In the US, we need to think about populations, about teamwork. It is an uphill battle because We are so individualistic and have built such fragmented systems.When I go to the NHS, I see a kind of dream.'

Dr Berwick also believes the right people are in charge of the NHS. 'You have great leaders, great advocates, people who understand and recognise the need for change', he says, before suggesting that this leadership starts at the very top.

'Who speaks for the British citizen in the NHS?' he asks. 'Tony Blair. I've seen the prime minister rivet his attention on dimensions ofperformance, insist that the ministry invest in those areas for improvement, expect results on his desk and hold people accountable.

'In the US, in 1998 or so, we had the National Cancer Policy Board report from the Institute of Medicine and the National Academy of Sciences. It said our cancer care wasn't what it should be and contained a strong set of findings about improvements. In the same year, the Organisation for Economic Co-operation and Development report on cancer outcomes in western Europe came out and I think it showed British cancer outcomes were among the worst in western democracies.

'In the US, there was some investment in cancer research, some discussion, a few retreats, but no national plan for improving cancer care, and to this day we do not have one. In the UK, the very month the OECD report came out, the prime minister said: 'Is this real? Why is it there? And how will we fix it?' And within a year, you launched the national cancer framework and the national cancer collaborative.

'One of the reasons I love the NHS is because It is political, because the political voice properly owned is the voice of the people. It is the consumer telling the system what it really needs to do.'

Mr Blair's concerns over cancer were, says Dr Berwick, 'the voice of the public', and because they were 'channelled through the political arm, the system responded'.

At a less elevated level, Dr Berwick picks out advocates of change such as Dr John Oldham, head of the National Primary Care Development Team. Dr Oldham's best-known success has been introducing GP practices to a system which allows them to dramatically cut waiting times, (See Raising the Game in Primary Care, HSJ special report, 14 November 2002).

'John took the US work on queuing theory, anglicised it, and proved it in a relatively small number of places, ' explains Dr Berwick. 'Then, under the leadership and encouragement of the ministry, you expanded it very fast to as much as 15-20 per cent of the GP system.You have proved you can do it and then spread it to a very large minority of the system. You are now well on the way to spreading that particular approach to scheduling and improving access to primary care. You haven't got total implementation yet, but you do have the fastest expansion and impact I've ever seen.'

Getting large minorities on board, as Dr Oldham did, is fundamental to Dr Berwick's strategy.He believes they will help win over NHS staff 'in the majority middle ground' by demonstrating improvements that can be widely understood and, therefore, disseminated'. Those entrenched in scepticism will, he admits, take more time to convince.

'The code here could be: 'Leave me alone. I am never gonna board the ship.' One out of six - maybe one out of five people, including doctors - will be in that group.The smart leaders leave them alone - they say: 'Fine, you do not want to be on this particular journey, I am sure you're taking a good one.' A lot of them also might be waiting for the absolutely hardest data, the mortality outcomes, and, of course, that takes time to get.'

As well as heading up IHI, Dr Berwick, as clinical professor of paediatrics and healthcare policy at Harvard medical school, is a leading clinician.While acknowledging that 'tensions are inherent in any large system', he thinks it 'a funny thing' that there is a 'tradition of conflict' in the NHS between the centre, the clinicians and the workforce.

'It would be nice if you could put down the swords for five minutes, ' he says, but quickly adds: 'do not get me wrong, I find the clinicians' interest in evidence to be both strong and valuable. I want doctors to be sceptical - I want everyone to be sceptical. Then when you have the evidence, when people can see what's improving, the process will spread.'

Despite his view that the NHS's structure gives it inherent advantages over the US model, he still believes it must move faster to establish patient journeys which are integrated across health and social care boundaries.While he is convinced that a desire to achieve this is in place at national level, he thinks it needs to filter down through the NHS more efficiently.

'For example, your hospitalisation stays are very long compared to US standards - in some cases double.Why? You certainly know the same medicine as we do. The reason is you can't get patients out of the bed - the beds are blocked.

'Patients need to go back into the community and get good support. But in whose interest is that?

For the GP, getting patients out of hospital sooner is just more workload. For the hospitals, getting patients out reduces their apparent bed days and so they are afraid they may have to downsize. In all of that, There is no sense of how effectively the patient is passed along the chain - and That is actually the real goal for your reforms.

'You can only make sense of that journey at a population-based level. One of the problems in the NHS is there is no authority at that level thinking about total resource allocation. You do have the strategic health authorities, but they need more responsibility, they need line budgets to do the work.'

It is on the current proposals for foundation trusts that Dr Berwick comes closest to courting controversy.He is in favour of the idea of these trusts developing clinical excellence and investing further in research and development to benefit the system as a whole. But should foundation status mean trusts effectively opting out of the system? Financially and structurally, he believes the overall modernisation drive could be threatened.

Putting it bluntly, he claims: 'It may make the hospitals greater, but not the system. In the end, the UK will have better care if it thinks in population terms than if it thinks in entity terms.'

Dr Berwick is equally ambivalent on targets. He is a fan to the extent that they reflect the ambitions of the NHS to improve. 'I would make some targets, along the lines of 'why do not we'. For example, 'why do not we in the next two years reduce total waiting by 50 per cent'. But I might stop short of these very specific threshold targets, where you say 'this is success and this is failure'.

'The problem with specific targets is not that they do not work - it is that they do work. If you tell me that my compensation and that my reputation is linked to mammography rate, I'll sure as blazes get a high mammography rate.

'The question that goes back to the target-setter, though, is: 'Is that what you really wanted?' Did you want a high mammography rate or do you want safe breast cancer care, a focus on the total patient journey through a cancer episode or world-class prevention?'

Dr Berwick also makes it clear that he does not think market pressures work well within the NHS.

'I do not think the sociology and structure of your systems are going to lead you to this kind of 'do better or I'll move' approach.

You do not have the social dynamics or the supply structures to make that work. Competition in short will hurt you, not help you.

Planning will help you and I would stick with the plan theory.'

Dr Berwick believes both the US and UK healthcare systems place too much emphasis on threats rather than encouragement. 'I am more of a carrot man. If I could coach the NHS harder, I would say: 'Let's stay away from the dark side of the Force.Work with the positive.Work with the champions, the volunteers and the bright side. Work with the positive motivation of the people and do not rely on fear. It will not work.'' Yet despite these reservations, Dr Berwick is optimistic about the UK modernisation process. It is just as well, for with his final words he stresses just how high the NHS has set its sights.

'You haven't met the final challenge - getting patient centredness, putting the patient in charge of the process, informing the patient - but then nobody really has.

'What the NHS is trying to do is probably bigger and more complex than the transformation of any economic sector in recent history.

Nothing this big, that I know of, has ever tried to improve this much. It will set a standard for industrial transformation in all sectors if It is successful.'