President Barack Obama’s appointment — during a congressional recess — of Dr. Donald Berwick to head the Centers for Medicare and Medicaid Services is focusing new attention on Berwick’s record and beliefs. Berwick, who had been the president of the Institute for Healthcare Improvement, has enthusiastic support for his new post from a broad array of medical, business and consumer groups, but key Republicans had raised objections to his nomination. They often point to a speech Berwick delivered on July 1, 2008, when Britain’s National Health Service celebrated its 60th anniversary. The NHS posted excerpts of the speech; here is a transcript with ellipses where the NHS edited the video.
Dr. Donald Berwick: Here, in the NHS, you have historically put primary care general practice where it belongs: at the forefront. The NHS is a bridge, it’s a towering bridge, between the rhetoric of justice, and the fact of justice. No one in their right mind could expect that to be easy.
Here, in England, accountability for the NHS is ultimately clear. Ultimately, the buck stops in the voting booth. You place the politicians between the public served and the people serving them. That is why Tony Blair commissioned new investment and modernization in the NHS soon after he took office, it is why the government has repeatedly modified policies in the search for traction, it is why your government now chartered the report by Lord Darzi. Government action in the NHS is not mere restlessness or meddling or recreation; it is accountability at work through the maddening, majestic machinery of politics.
In the United States, we fund health care through hundreds of insurance companies. Any American doctor or hospital interacts with a zoo of payment streams. Administrative costs for that zoo approach 20% of our total health care bill, that’s at least three times as much as in England, maybe more.
In the United States, these hundreds of insurance companies have a strong interest in not selling health insurance to people who are likely to need health care. Our insurance companies try to predict who will need care, and then to find ways to exclude them from coverage through underwriting and selective marketing. That increases their profits. Here, you know that that is not just crazy; it is immoral.
So, you could have had a simpler, less ambitious, less troubled plan than the NHS. You could have had the American plan. You could have been spending 17% of your GDP to make 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 supply. You could have made hospitals and specialists, not general practice, your mainstay.
You could have obscured you could have obliterated accountability, or left it to the invisible hand of the market, instead of holding your politicians ultimately accountable for getting the NHS sorted. You could have let an unaccountable system play out in the darkness of private enterprise instead of accepting that a politically accountable system must act in the harsh and, admittedly, sometimes very unfair, daylight of the press, public debate, and political campaigning. You could have a monstrous insurance industry of claims, and 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 recognizing that sick people tend to be poorer and that poor people tend to be sicker, and that any health care funding plan that is just, equitable, civilized, and humane must must redistribute wealth from the richer among us to the poorer and less fortunate. Excellent healthcare is by definition redistribution. Britain, you chose well.
Is the NHS perfect? Far from it, far from it. I know that as well as anyone in this room. From the front line to Whitehall, I have had the privilege to observe its performance and even to help to measure its performance. The large scale facts are most recently summarized in the magisterial report by Sheila Leatherman and Kim Sutherland sponsored by The Nuffield Trust, the report called The Quest for Quality: Refining the NHS Reforms. They find some good news. For example, after ten years of reinvestment and redesign, the NHS has more evidence-based care, lower mortality rates for some major disease groups (especially cardiovascular diseases), you have lower waiting times for hospital, outpatient, and cancer care now, more staff and technologies are available, you have in many places better community-based mental health care, and you are starting to see falling rates of hospital infection.
Important, large scale patient safety campaigns have begun here in England, as well as in your cousins in Wales, Scotland, and Northern Ireland. There is less progress in some areas, especially by comparison with other European systems, such as in specialty access, in cancer outcomes, in patient-centeredness, in life expectancy and infant mortality for socially deprived populations. In other words, in improving its quality, two facts are true: the NHS is en route, and the NHS has a lot more work ahead.
So how can you do even better? I have ten suggestions:
First, put the patient at the center put the patient at the center of your system of care. Put the patient at the center for everything you do.
Second, stop restructuring. In good faith, in good faith and with very sound logic, the leaders of the NHS and the government have sorted and resorted local, regional, and national structures into a continual parade of new aggregates and new agencies. Every single change makes sense, but the parade doesn’t make sense. It drains energy and confidence from the workforce and the middle managers, who learn not to take risks, but rather to hold their breaths and to wait for the next change. It is, I think, time to stop. No structure in a complex management system is ever perfect. Every structure brings with it both good news and bad. There comes a time, and the time has come, for stability, on the basis of which, paradoxically, productive change becomes easier and faster, as the good, smart, committed people of the NHS the wonderful one million people find the confidence to try improvements without fearing the next earthquake.
Third, strengthen the local health care system community care systems as a whole. What you call “health economies” should become the core of design: the core of leadership, management, inter-professional coordination, and goals for the service. This is the natural unit of action for the Service, but it is yet unrealized as a unit of action. I personally believe that the NHS has gone too far in the past decade toward optimizing hospital care which is a fragment and has not yet optimized the processes of care for communities. You can do that. I think it is your destiny to do that.
Fourth, to help do that, reinvest in general practice and primary care. These, not hospital care, are the soul of a proper, community-oriented, health-preserving care system. General practice, not hospitals, is the jewel in the crown of the NHS. It always has been. You must save it. And you must build it.
Fifth, please don’t put your faith in market forces. It is a popular idea: that Adam Smith’s invisible hand would do a better job of designing care than leaders with plans can do. I do not agree. I find little evidence anywhere that market forces, bluntly used, that is, just consumer choice among an array of products with competitors’ fighting it out, leads to the health care system that you want and need.
Sixth, avoid supply-driven care like the plague. Unfettered growth and pursuit of institutional self-interest has been the engine of low value in the United States’ health care system. It has made it unaffordable, and it has not helped patients at all. Seventh, develop an integrated approach to the assessment, assurance, and improvement of quality. This is a major recommendation of Leatherman and Sutherland’s report, and I totally concur. England now has many governmental and quasi-governmental organizations concerned with assessing, assuring, and improving the performance of the NHS. But they don’t work well or seamlessly with each other.
Eighth, please heal the divide among the professions, the managers, and the government. Since at the least the mid-1980’s, a rift developed that has not yet healed between the professions of medicine formally organized and the reform projects of government and the executive. I assume there is plenty of blame to go around on this, I assume that the rift grew despite the best efforts of many leaders on both sides. But, the toll has been very heavy: resistance, divided leadership, demoralization, confusion, frustration, excess economic costs, and occasionally technical mistakes in the design of care. The NHS and the people it serves can ill afford another decade of misunderstanding.
Ninth, train your health care workforce for the future, not for the past. That workforce will need to master a whole new set of skills relevant to the leadership of and the citizen in, the citizenship in the improvement of your health care as a system patient safety crucial, continual improvement, teamwork, measurement, patient-centeredness, and so on, to name but a few.
Tenth, and finally, aim for health. I suppose your forebears could have called it the NHCS, the “National Health Care Service,” but they did not. They called it the “National Health Service.” Maybe they meant it. Maybe they meant to create an enterprise whose purpose was not care, but health. Maybe they knew then, as we surely know now, even before Sir Douglas Black and Sir Derek Wanless and Sir Michael Marmot, that great health care, technically delimited, cannot alone produce great health.
The only thing that exceeds my admiration for the NHS is my hope for the NHS. I hope that you will never, never give up on what you have begun. I hope that you realize and reaffirm how badly you need, how badly the world needs, an example at scale of a health system that is universal, accessible, excellent, and free at the point of care a health system that is, at its core, like the world that we wish we had: generous, hopeful, confident, joyous, and just. Happy birthday!
The full text of speech, A Transatlantic Review of the NHS at 60 , includes this beginning remark: “I am romantic about the NHS; I love it. All I need to do to rediscover the romance is to look at health care in my own country.”
KHN also has a resource guide about Dr. Donald Berwick, with links to profiles, news summaries abbout his nomination and appointment, and more speeches and interviews with Berwick.
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