Heroes Not Zombies

As part of the NHS’s 60th anniversary celebrations, Donald Berwick, President of the US organisation, the Institute for Healthcare Improvement, made a speech at one of the specially organised conferences. I’ve always been impressed by his writing and his speeches. I first encountered them when I read “Crossing the Quality Chasm” – the book which introduced me to the concept of “complex adaptive systems”, and I thoroughly enjoyed his “Escape Fire” ( a collection of ten of his annual addresses ).

His speech, in praise of the NHS, compared it very favourably to the state of health care in the US. In summary, he said this –

You could have had the American plan. You could have been spending 17% of your gross domestic product and making health care unaffordable as a human right instead of spending 9% and guaranteeing it as a human right. You could have kept your system in fragments and encouraged supply driven demand, instead of making tough choices and planning your supply. You could have made hospitals and specialists, not general practice, your mainstay. You could have obscured accountability, or left it to the invisible hand of the market. You could have a giant insurance industry of claims, rules, and paper pushing instead of using your tax base to provide a single route of finance. You could have protected the wealthy and the well instead of recognising that sick people tend to be poorer and that poor people tend to be sicker, and that any healthcare funding plan that is just must redistribute wealth. Britain, you chose well. As troubled as you may believe the NHS to be, as uncertain its future, as controversial its plans, as negative its press, as contentious its politics, please behold the mess that a less ambitious nation could have chosen.

He then went on to make ten suggestions for improvement. The first, I think was the most important and one that most health care systems haven’t even begun to implement on any significant scale –

Put the patient at the absolute centre of your system of care—In its most authentic form, this rule feels very risky to both professionals and managers, especially at first. It means the active presence of patients, families, and communities in the design, management, assessment, and improvement of care. It means total transparency. It means that patients have their own medical records and that restricted visiting hours are eliminated. It means, “Nothing about me without me.”

Apart from that he recommended strenghtening the Primary Care and Community aspects of the service, stopping the habit of more and more “reforms”, a strong plea NOT to pursue a market-led direction (ie I suspect, to do more like the Scottish NHS than the English one), and paying attention to the training and integration of the diverse employees of the NHS. Finally, he recommended aiming at health itself, not just health care.

He is astute enough to know that “great health care, technically delimited, cannot alone produce great health”. Of course it would be nice if the NHS was structured around trying to improve the health of its users, but the real big changes in health as such will be achieved through political means and societal changes, not health care ones.