US health expert Professor Don Berwick was appointed this year by the UK Prime Minister David Cameron to review patient safety in the National Health Service (NHS) following a scandal around care at the Mid-Staffordshire hospital. 
Publishing his report earlier this month, Professor Berwick described the NHS as ‘a globally important treasure’ but said it had some important problems, including: ‘a partial loss of focus on quality and safety as primary aims, inadequate openness to the voices of patients and carers, insufficient skills in safety and improvement, staffing inadequate for patients’ needs, and very unhelpful complexity and lack of clarity and cooperation among regulatory agencies.’
Tim Senior, GP and regular Croakey contributor, says the lessons drawn by the Berwick Report are just as relevant to Australia.
*****
For all of us who work in health services, the thought of people coming to harm while under our care is what keeps us awake at night. The standards of care revealed at the Mid-Staffordshire hospital in the UK and explored through a number of enquiries are enough to wake people in dense sweats for years to come. The Twitter hashtags #Francis and #Keogh have been compelling reading for health professionals, managers, politicians and journalists seeking to digest their reports. Now we have #Berwick, with the release of the report on patient safety by Don Berwick, the well-known, and well respected, US health advisor and his small team of experts. Interest in his report has not been confined to the UK: there has been rapid social media reaction around the world, including commentary in Canada, and I’m sure I won’t be the only one commenting in Australia.
The report itself is short (46 pages) and simple enough for everyone to read in full. At its core is essentially a call to bring about culture change. Berwick sees clearly the sort of health service that is able to minimise patient harm: one that puts patient safety at its heart. It is a service that hears the patient voice, brilliantly “even the voice that whispers”, and is constantly learning, particularly from its own mistakes. It is a service that is “a joy to work in”.
Berwick sees the risks of barriers along the path to this ideal, safe, health service. So, in presenting his report to the Government, he writes targeted letters to all those who could pose those risks, explaining why they need to help, engaging them in the process of culture change. These letters, addressed to the general public, senior government officials and executives, and to NHS staff and clinicians, all send a consistent message: don’t blame the staff.
He sets out four guiding principles:
- 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.
Throughout the report, there are messages for these audiences, particularly to senior government officials and senior executives. Politicians are clearly included in this group. He cautions about the use of quantitative targets, especially financial targets, which can easily drown out patient and staff warnings on safety. There are carefully written sections challenging UK Health Secretary Jeremy Hunt’s assertion that he wants a “zero harm” NHS. You asked us for advice: we’ll decide on the advice we give, he says. And then warns that the goal of reducing harm is a constant striving, not a battle that gets won.
Relevance for Australia
This makes sense, of course, to anyone working in health services. Every system has its store of memories about patient safety disasters. Where the UK NHS has Mid-Staffordshire and Bristol Paediatric Cardiac Surgery, in Australia we have had Camden and Campbelltown hospitals (PDF) and miscarriages on the front pages. What relevance then might this report have for Australia? Let’s go through the recommendations.
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.
There is not a single person who would disagree with these two recommendations. However, in Australia, as everywhere else, the challenge comes in putting them into practice. Australia’s complex system of federal and state health bureaucracies makes it harder for an organisation to learn from its mistakes. Where are the mechanisms for learning from errors across states? It’s not that it doesn’t or can’t happen, but that the arrangements are ad hoc. In community settings this is even harder. There is a system of accreditation for general practices which does include some of the issues identified in this report. But not all practices are accredited and errors often occur across the boundaries of organisations, such as between social services and health care or child protection and the health sector.
This sentence might put a chill through politicians and managers: “Where scarcity of resources threatens to compromise safety, all NHS staff should raise concerns to their colleagues and superiors and be welcomed in so doing.” How eager are we to embrace that in state funding for our hospitals? Which politician will welcome concerns raised on their funding model? Could we see the increase in gap fees as a patient safety issue, if more people are delaying their treatment? New South Wales Department of Community Services child protection staffing levels recently hit the headlines. The nettle to be grasped here is the difference between saying we’re doing it and actually doing it.
3. Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.
This is another recommendation everyone will agree with. However in Australia, I’m not sure we’ve even begun to think what such a health system would look like. Granted, we do have organisations now that might allow the patient’s voice to be heard more widely – I’m thinking of the Consumer’s Health Forum and Patient Opinion. But I’m sure neither of those organisations would claim to be at the centre of health decision-making in this country, or that health services are routinely set up to listen to what they have to say.
How big is this task? I think massive culture change is needed. Imagining a different world shows the scale of the changes. Political health debates would be led by patient groups, not health groups. Health policy would centre around the patient experience. We’d see community representatives at board level, perhaps even outnumbering the doctors. We’d take inequality of access seriously. We’d have a discourse that blamed patients less (even subtly in the language used) and helped them more.
The main examples in Australia that show what happens when this is done are Aboriginal Community Controlled Health Organisations. They are owned and run by the community, with boards elected by the community. There is evidence (PDF) that this structure achieves better health outcomes. If we really wanted to have patients at the centre of our health system, we’d be knocking down the doors at the National Aboriginal Community Controlled Health Organisation (NACCHO) asking them how to do it, rather than thinking of the Aboriginal health sector as a case of special pleading. (It is worth noting in passing, that there are a few non-Aboriginal health co-operatives around, too).
Education is mentioned in the text of this recommendation. Having the patient voice involved in training health professionals will start the culture change required, and I have argued that more fully previously on Croakey.
4. Government, Health Education England and NHS England should ensure 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.
There are two areas in Australia where this recommendation is a live issue right now. The first is in hospital staffing levels, which have resulted in nurses going on strike in NSW recently. The second is in rural areas, and also, it is becoming apparent, in outer metropolitan areas. Discussion on this is currently framed around workforce or budget issues in the main. Would anything change if these were debated as patient safety issues?
There is also a call for better evidence around staffing levels and staffing ratios required for patient safety, with the National Institute for Health and Care Excellence (NICE) suggested as the organisation to do this in the UK. Health Workforce Australia has done a lot of work describing the current workforce and future needs here could well do this task usefully in Australia.
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.
“The most powerful foundation for advancing patient safety … lies much more in its potential to be a learning organisation, than in the top down mechanistic imposition of rules, incentives and regulations.”
The ability of Australia’s health system to be one that learns from all its disparate parts would perhaps be expecting too much. Australia is no different to anywhere else in the world, in having its clinical education ignore quality and patient safety practices almost completely. There are, however, some good examples of this sort of expertise in Australia already – the Australian Primary Care Collaboratives, run by the Improvement Foundation, which are also rolling out other work based on this, and One-21-Seventy in Aboriginal community controlled services. If Australia’s health systems really want to become learning organisations, they can’t just contract a few customised training sessions, they need expertise supporting practitioners at the front line. They also need time dedicated to quality improvement activities, which is time away from the patient. This can pose problems for capacity in a stretched system, and appears inefficient because fewer patients are seen (more safely). It’s also worth pointing out that in the current system Medicare doesn’t fund work that is not face-to-face with a patient. Practices face a financial disincentive to do quality improvement work, particularly as Medicare rebates fail to keep pace with inflation.
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.
All politicians need to read this section of the report in full. Reading this headline will allow them to say “Oh yes, we agree with this. Look how transparent we are with our data. Look at the My Hospitals website.” The full section is unequivocal in saying this is not what it means. It is asking for data that matters to be released:
“…the perspective of patients and their families; measures of harm; measures of the reliability of critical safety processes; information on practices that encourage the monitoring of safety on a day to day basis; on the capacity to anticipate safety problems; and on the capacity to respond and learn from safety information.”
Wow! That’s not waiting times! It is also clear that this data should not be used for performance management or comparing organisations. Like the My Hospitals website.
8. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.
This recommendation goes with the previous one, and is to get at variation within a service which may be hidden in aggregate scores, and learn from more fine-grained feedback. The patient and carer voice, if listened to, can act as an early warning for bigger failures. In a sense, it’s surprising that this needs to be recommended. Outside the health sector, private companies delivering services to people are always wanting to hear the voice of their customers, and perhaps we should listen more to Disney on this!
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.
This recommendation could have been written for us in the Australian health system, with its complexity and diffusion of responsibility. Our system has 6 States and 2 Territories overseeing hospitals and some community services, with the Federal Government overseeing funding for private general practices and specialist services and also providing some funding to medical insurance. Medicare Locals are dotted throughout the country, regulation of practitioners is by the Australian Health Practitioner Regulation Agency (AHPRA), and there’s input from Regional Training Providers and general practice education and training (GPET) into training, workforce agencies, professional colleges, unions and lobbying organisations. Though priorities are broadly similar, they each have their own goals and targets. Everyone says they advocate for patient outcomes but there’s a lot of self-interest and few patient voices. This doesn’t even mention the social care sector, or local government, though if we are serious about tackling the social determinants of health, they will also have a role. The danger here is the diffusion on responsibility, what Michael Balint, in his classic book The Doctor, his Patient and the Illness called ‘the collusion of anonymity’. This, I suspect, will be a permanent challenge. The goodwill of staff acknowledged here, though, should be a significant strength on which to draw.
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.
If the message of the report could be summed up, this would be it: Blaming staff does not work. We need to have organisations and systems that can learn, which actually means accepting that mistakes will happen and learning from them. Retribution, blame and sanctions will only create fear and a culture of covering up mistakes. Wilful or reckless neglect is, thankfully, rare, and is not the cause of the vast majority of errors in health services.
So, that’s the Berwick Report. The lessons are applicable to health services across the world, and our health system is no worse and no better at avoiding patient harms. There are clear pressures identified by Berwick that will pull against patient safety, often because patient safety disasters play well in the media, and blame is the first reaction.
As a clinician, I am untrained in safety – as the report points out – and can be a bit naïve in my understanding of the complexities of this. However, if the Berwick Report is to be effective, then clinicians of goodwill across the country will need to be able to put its recommendations into action on the ground, supported by managers and politicians. I for one would like to work in a service with this aim: “Make sure pride and joy in work … infuse the [health system]”. That would help all of us sleep more easily at night.
