Surveillance of managers is 'toxic' says Don Berwick

In an interview with HSJ, Professor Don Berwick said the NHS placed “too much emphasis on accountability, supervision and metrics” and “not enough about relationship development”.

“When the workforce is being too closely monitored with measurements, compliance and ticking boxes it creates moral problems and makes it much harder,” added Professor Berwick, who led a major review into patient safety in 2013 and was once President Obama’s health adviser.

In February this year, Tom Kark QC published his review of the “fit and proper person test” for NHS board members. Of the seven recommendations made, the government agreed to adopt two – a set of “competency standards” for NHS directors and a central database with information about senior NHS managers’ qualifications and employment history – but did not go as far as agreeing to “strike off” directors or managers.

Mr Kark was asked to carry out the review after a report by Bill Kirkup into Liverpool Community Health Trust revealed  poor managers were moved into new roles in the NHS.

But Professor Berwick told HSJ “too many leaders [in the NHS] are fearful and feeling like one slip-up and they are in trouble”.

“You can’t expect maturing, risk-taking leadership in an atmosphere of fear,” he said. “Creating a sense of pride and confidence in leaders is really important.”

Professor Berwick, who is currently a King’s Fund visiting fellow, also stressed the need for the upcoming workforce plan to invest in leaders’ training and development and “create the environment so people feel good about their work”.

“I hope that the workforce plan includes development of behaviour characteristics and skills of the leaders,” he added.

Professor Berwick also said building cooperation at integrated care system level is “one of the really important frontiers for the NHS now”.

He stressed the need for local variation, commenting: “Do not expect care processes to be the same. They shouldn’t be the same and that would be a mistake.”

Professor Berwick added that, although the idea of moving the system to integrated care “is right”, the long-term plan “does not complete the story around integrating health and social care”.

“To me, that is the next mountain to climb,” he said. “You can’t get integrated care with the results you want if you can’t begin to embrace the social care sector. The rhetoric is there but we don’t see the mechanisms there for that to happen.”

The long-term plan, published in January, stated all of England should be covered by ICS by 2021. 

Professor Berwick said that, while the NHS and the long-term plan is “getting on the right track”, the social care system “needs attention”. 

“I hope political leaders understand that,” he said. “Find new money and put [it] into social care or move resources from acute care into social care.”

He added: “You can’t keep cutting the budget and expect excellence – you have to get efficiency by cooperating better instead of by cutting the institutional budget.”