The Berwick Review - my conclusions.

I would summarise the Berwick Review like this;

Problems happen in all health organisations, including the NHS which is probably the finest and most idealistic of them all. To honour the victims, we should endeavour to ensure that it never happens again.

‘Zero harm’ is an impossible dream but we can work towards it, if only we can change the culture.

The NHS should be a learning organisation and work as a team.

No more fear, no more blame.

Put patient safety first.

Hmmmmm. Am I being really cynical?

How about this –

The ‘Liverpool Care Pathway’ was intended to ease the terminally ill into death gently, by withdrawing food and hydration at the very end, following careful discussions and planning with the patient, their relatives and carers.

In fact, the government offered a financial inducement to hospitals to put as many terminally ill people as possible on that ‘pathway’.

Meanwhile the managers had closed so many wards that they were desperate for the beds.

The discussions didn’t happen, consent wasn’t bothered with. People were put on the ‘pathway’ too early. It became involuntary euthanasia, with a financial bonus and a free bed every time a patient got put on the ‘pathway’.

Real, live human beings were treated terribly.

Good, decent people felt obliged to defend it.

After a number of years, another scandal and another report – and it is going to be quietly scrapped.

So it isn’t the ‘culture’, its government, lack of resources, bad management and too much pressure.

 

What is missing in the report?

1) Bad management.

Starting at the very top, the NHS has been badly managed by people with no clinical knowledge who were either second rate civil servants or failed private sector managers. Their main achievement has been laying off workers, closing wards, shutting hospitals and paying themselves very well.

2) The clinical harm in hospitals is mainly caused by a tiny minority of doctors and nurses who are either lazy or incompetent. Usually a mixture of the two. They leach off their colleagues because, unfortunately, they are shielded by workmates who cover for them.

3) There is an atmosphere of fear in the NHS – not fear of being caught out for incompetence but fear of questioning management orthodoxy.

4) There is no democratic control – for patients, staff or local authorities. Who pays for it all? Who does it belong to? Who does all the work?

5) Too much of the NHS is in private hands, people with vested interests, making money.

G.P.’s, Opticians, Pharmacists, Dentists are all in private, profit making business for themselves. They are subcontracted by the state to do medical work on our behalf and very profitable it is too.

Increasingly, peripheral work like cleaning, maintenance, testing and analysis has been subcontracted to profit making multi-nationals.

The Pharmaceutical industry makes Billions out of our NHS and puts little back in.

6) Bullying is normal.

Consultants bully junior doctors and nurses.

Nurses bully care assistants.

Managers bully consultants.

Racism and sexism are everywhere.

7) The ‘Never Events’ say it all, a list of things that should never happen in a hospital, because there are systems (like check lists) in place to prevent them. Yet they go on happening.

 

I’m going to stop there for the moment, I’m going to develop my own plan for the NHS over the next few weeks.

I’ve got a backlog of research I need to write up, but these days finding the ability to concentrate is harder for me. Here’s a taste;

I’m going to review the front runners for the job of Chief Executive of NHS England, now that there will be a vacancy. I think I’ll do my own countdown of undesirables – in reverse order of course.

I’ve been taking a little look at ‘The Foundation Trust Network’ – that’s interesting.

And there’s a lot more besides.

And your comments are always welcome.

Neil Harris

(a don’t stop till you drop production)

Home: helpmesortoutthenhs.blogspot.com

My review of The Berwick Review, Part 2.

 

I slogged my way through the main body of the report. It’s probably the shortest of the recent studies, with the fewest boring footnotes, addendums and figures. It’s also perhaps the least helpful. There’s not much data there and as you should know from me by now, original data is like finding a vein of ore in rock.

It seems to be a selection of powerpoint presentations and flipchart images. I can see these being ‘cascaded down’ throughout the NHS in the months to come.

That’s the correct managementspeak, I think.

I can also see tired and depressed people just turning off as one page merges into another.

Here are the good intentions, nothing anyone could disagree with here;

“Place the quality of patient care, especially patient safety, above all other aims.

Engage, empower, and hear patients and carers at all times.

Foster whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work.

Embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.”

Here a fine sentiment, again no problem with that;

“At its core, the NHS remains a world-leading example of commitment to health and health care as a human right – the endeavour 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. But the events at Mid Staffordshire have triggered a need to re-examine what the NHS does and determine how it can improve further. The only conceivably worthy honour due to those harmed is to make changes that will save other people and other places from similar harm.”

 

Here are the problems;

“The following are some of the problems we have identified:

●Patient safety problems exist throughout the NHS as with every other health care system in the world.

●NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.

●Incorrect priorities do damage: other goals are important, but the central focus must always be on patients.

●In some instances, including Mid Staffordshire, clear warning signals abounded and were not heeded, especially the voices of patients and carers.

●When responsibility is diffused, it is not clearly owned: with too many in charge, no-one is.

●Improvement requires a system of support: the NHS needs a considered, resourced and driven agenda of capability-building in order to deliver continuous improvement.

●Fear is toxic to both safety and improvement.”

 

Here the solutions;

 

“To address these issues the system must:

●Recognise with clarity and courage the need for wide systemic change.

●Abandon blame as a tool and trust the goodwill and good intentions of the staff.

●Reassert the primacy of working with patients and carers to achieve health care goals.

●Use quantitative targets with caution. Such goals do have an important role en route to progress, but should never displace the primary goal of better care.

Executive Summary

 

●Recognise that transparency is essential and expect and insist on it.

●Ensure that responsibility for functions related to safety and improvement are vested clearly and simply.

●Give the people of the NHS career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning.

●Make sure pride and joy in work, not fear, infuse the NHS.The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.

And here the recommendations;

We have made specific recommendations around this point, including the need for improve training and education, and for NHS England to support a network of safety improvement collaboratives to identify and spread safety improvement approaches across the NHS.”

Our ten recommendations are as follows:

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

2. 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. Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.

4. 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 organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported.

5. 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.

6. The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS.

7. Transparency should be complete, timely and unequivocal. All data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.

8. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.

9. 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.

10. 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 wilful or reckless neglect or mistreatment.”

My conclusions tomorrow.

Neil Harris

(a don’t stop till you drop production)

Home: helpmesortoutthenhs.blogspot.com

My review of the Berwick review. Part One.

I think if a left wing trouble maker like me was the Health Minister and I had to appoint someone to review the culture in the NHS with a view to protecting patients from the kind of treatment they received at Stafford Hospital in the Mid-Staffs NHS Trust, I’d probably appoint the most critical person I could find.

In my case it wouldn’t necessarily be an American, free-market neo-con fiscal conservative, fundamentally opposed to ‘socialised medicine’, but I’d be looking for a real critic.

Seriously, it’s time for criticism and then changing things.

In fact, Professor Berwick (President Obama’s healthcare advisor) is clearly sympathetic to and supportive of our NHS. I love where he’s coming from but I fear he’s just a bit too sympathetic.

Perhaps that’s why a conservative health minister who has failed to follow the important recommendations of the Francis enquiry appointed him.

This is from his letters to Clinicians, Managers and Staff:

“For the nearly three decades that I have been able to observe and work with the NHS, nothing has impressed me more than you – the workforce of 1.3 million people who are trying to make real a vision of a vital, universal health care system, accessible to all, and free at the point of service. Your nation’s commitment to health care as a human right and to healing as a shared mission is second to none in the world. And all of that is possible through you; only through you.”

This is from his letter to the Government and includes the ideals he wants to see governing policy;

“A culture of learning can….. and the likelihood of such a culture’s thriving in the NHS depends, more than on anything else, on how you, the senior leaders, behave, speak, and invest.

These are four guiding principles that, I suggest, should inform every step you take in these matters – in what you think, say, and do:

● Place the quality and safety of patient care above all other aims for the NHS. (This, by the way, is your safest and best route to lower cost.)

● Engage, empower, and hear patients and carers throughout the entire system, and at all times

● Foster wholeheartedly the growth and development of all staff, especially with regard to their ability and opportunity to improve the processes within which they work.

● Insist upon, and model in your own work, thorough and unequivocal transparency, in the service of accountability, trust, and the growth of knowledge.

Time and again in our Group’s deliberations, every member used the word “culture” to diagnose both the faults of and the possibilities for the NHS. I urge you to focus on the culture that you want to nurture: buoyant, curious, sharing, open-minded, and ambitious to do even better for patients, carers, communities, and staff pride and joy. If you read our recommendations carefully, and act on them, I believe that you will have set your compass right.”

 

This is from his letter to the people of England;

“What you do have in the NHS is something that most other nations in the world don’t have: a unified system of care that is completely capable of identifying its problems, admitting them, and acting to correct them.

That is the process now underway; that is the process that led your leaders to convene our Advisory Group; and that is the process that can and, I believe, will help the English NHS to emerge over time as one of the safest health care systems in the world.

That is not easy. And it gets even harder if the staff of the NHS experience a culture of fear, blame, recrimination, and demoralization. I hope that you resist such general negativity, in yourself and anyone else, and instead clearly point the way with energy and optimism toward the care that you and I want, and that the vast majority of people who work in the NHS want to offer.”

And this is what he wants us to be doing in future;

“patients, carers, and citizens – have a vital and exciting role to play. Your voice is key to the future. I hope that this report will give you more confidence in speaking up everywhere and all the time in a vital NHS, and will give those who care for you and want to help you the confidence and skills to invite you, hear you, and welcome you into authentic partnership.”

 

When I hear references to ‘culture’ in the NHS, I just hear an echo of Sir David Nicholson’s voice going on and on about ‘NHS culture’. That’s something you can read for yourself in his Blog and his interviews. I’ve been following his progress as he’s been winding down (yawn), doing a valedictory tour (thank you, thank you), cementing his legacy (groan).

Frankly it’s not just about culture but I’ll come on to that later.

Neil Harris

(a don’t stop till you drop production)

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