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Don Berwick: Culture of fear stands in the way of NHS progress

The US health policy expert who is supporting new models of care in England visits a successful vanguard site, where staff have found ‘new joy in their work’.
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The US health policy expert who is supporting new models of care in England visits a successful vanguard site, where staff have found new joy in their work

Don Berwick is a leader in health policy and improvement. He co-founded the Institute for Healthcare Improvement, ran the US Medicaid and Medicare programmes in the early part of Barack Obamas presidency, and was a leading figure in the extension of health insurance to people who struggled to afford it.

In the UK, he was asked to report on improving patient safety in the wake of the Francis report into Mid-Staffordshire NHS Foundation Trust. Now he is spending several weeks a year supporting the vanguard areas introducing new models of care in a bid to improve outcomes and provide more sustainable health care.

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The US health policy expert who is supporting new models of care in England visits a successful vanguard site, where staff have found ‘new joy in their work’   


Professor Don Berwick meets with staff from the Sutton Homes of Care vanguard

Don Berwick is a leader in health policy and improvement. He co-founded the Institute for Healthcare Improvement, ran the US Medicaid and Medicare programmes in the early part of Barack Obama’s presidency, and was a leading figure in the extension of health insurance to people who struggled to afford it.

In the UK, he was asked to report on improving patient safety in the wake of the Francis report into Mid-Staffordshire NHS Foundation Trust. Now he is spending several weeks a year supporting the ‘vanguard’ areas introducing new models of care in a bid to improve outcomes and provide more sustainable health care.

It’s a role Professor Berwick relishes. On a visit to Crossways Nursing Home in Sutton, South London, to hear about one of the vanguard sites focusing on care homes and their interaction with the NHS, he quickly gets to grips with the details of the project and questions those present about what has driven the success of the project.  

‘You are awesome,’ he tells the nursing home staff, local community services, voluntary groups and local hospital staff. ‘It is clear that every one of you is a leader. And you are smiling – that is not a characteristic of the NHS at the moment.'

Shift in culture

The successes of the Sutton scheme are already beginning to show. There has been a 15% reduction in emergency department attendances. Patients from care homes going into hospital are given the scheme’s ‘red bag’, containing information about their health background as well as everything they need for a hospital stay. Patients with the red bag have a four-day shorter length of stay than those without.

For Professor Berwick, much of this success is due to a shift in culture. He says despite the pressures on the NHS, that staff involved in the vanguard scheme have found new joy in their work. He sees the success of such schemes as delivering on two aims: improving care and reducing costs. 

However, the way inwhich the scheme is replicated and spread is crucial, with three significant elements, he says. The first is consistency across the immediate area: are all care homes performing the same, for example. The second is whether there is a spread of good ideas between the vanguards, something that is already beginning to happen. And finally, will there be an expansion to the rest of the NHS? This last area is ‘not quite solved’  in the current scheme, Professor Berwick says. Vanguard models, he adds, will probably need to be adapted to fit different local circumstances.

‘If you look at the progress made in Sutton, it is relationship-based progress,’ he says. ‘It is great that they are sitting together and getting to know each other. The red bag is not a cause of cooperation. It is an effect of it.’

Supporting learning 

His work on patient safety post-Mid-Staffordshire led to a series of recommendations that must be ‘complete, timely and unequivocal'. These include implementing a culture of learning, adequate evidence-based staffing levels and transparency. 

As for how well he feels this has been carried out, ‘It is not for me to judge’, he says. ‘The people who have to act on these recommendations have many other priorities. I’m not in a position to second-guess them. The uptake on implementation is encouraging but incomplete.

‘The core message from the report was that for the NHS to thrive it has to be a learning system, and learning is incompatible with fear. It involves supporting growth and development of knowledge and new relationships with patients and carers. Some of that has been picked up. The vanguards are prime examples of supporting learning.’

But Professor Berwick warns that some areas of the NHS might not be supportive: ‘There continues to be a sense in the NHS of fear, of being watched and the consequences of error,’ he says.

He does not support mandatory staffing ratios. ‘I have been sceptical of the view that safety can be achieved with rigid rules about ratios,’ he says. ‘Safe staffing depends on other factors as well as just numbers. The amount of stress in the NHS is a very real problem. We have to listen to the nurses when they say there are not enough people.’

Instead, he would like to see more awareness raised about the stresses facing staff, which requires good relationships and better funding. 

A ‘dangerous time’ 

Speaking on the day of President Trump’s inauguration, amid speculation that the Affordable Care Act, otherwise known as Obamacare, will soon unravel, Professor Berwick says he is ‘extremely worried’ that 30 million people could lose their health coverage. ‘Obamacare has extended coverage to more than 20 million Americans and has given us a whole new set of tools for helping doctors and hospitals improve care,’ he says. The expansion of Medicaid, the government-funded scheme for some of the poorest population, helped another 10 million people, he adds.

‘It was a massive step forward. There were some glitches, but with the proper ethos in Washington it could have been fixed,’ he says. ‘They do not have a plausible plan for replacing it with something equally effective. It is a very dangerous time.

‘Hopefully public pressure and good sense in Congress will stop or mitigate it.’ A few hours later comes the news that the process to scrap Obamacare has started. 


Alison Moore is a freelance health writer  

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