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Improvement is everything

Spiralling demand and dwindling resources mean many parts of the NHS are just about managing to cope day-to-day – often leaving little time to consider or implement projects to improve care and outcomes. Peter Blackburn looks at health leaders’ bids to put quality improvement at the heart of the health service

Don Berwick’s roles and career experiences have been complex, detailed, technical and, ultimately, vast.

Formerly the administrator of Barack Obama’s Medicaid, Professor Berwick has published more than 100 articles on healthcare policy in professional journals, co-authored several seminal books and been a senior leader at Harvard Medical School, Boston Children’s Hospital and Massachusetts General Hospital.

But ask the King’s Fund visiting professor how the NHS can genuinely embed quality improvement in its day-to-day business and the answer he gives is actually rather simple.

Just look at my grandson Nathaniel, he said.

‘If you want to understand quality improvement and how you embed it in the NHS just watch a child. My grandson Nathaniel is a baseball addict – he can’t stop getting better. He’s always reading about it, watching it, out in the yard practising. He wants a new glove, a new bat, he watches the coach, speaks to his dad and he practises and practises and he never does it the same twice. He knows if he keeps swinging the same way he’ll get the same result.

‘He does it often with joy – not always, sometimes when it goes wrong he is crying, but all the time he’s trying to get better and he’s doing it by learning.’


Practice makes perfect

Speaking at a King’s Fund conference discussing quality improvement Professor Berwick said the processes the health service needed to follow were the same that his grandson does in his continuous efforts to be better.

The first key part is having a clear aim, Professor Berwick said.

‘He knows what he needs to get done: hit the ball as far as he can, run the bases quickly, learn to catch and throw well. He has measurements and audits – he sees where the ball goes all the time. He’s an avid measurer.’

This theory might cause a tremor for healthcare professionals already browbeaten by the Care Quality Commission, NHS England and NHS Improvement – among others – from a host of different angles.

But there is a difference.

‘Not one bit of it is external,’ Professor Berwick says, ‘no one is coming in with rewards and punishments, it’s all about learning.’

He added: ‘The other thing he has is a method to learn – he has a goal to hit the ball as far as he can but he has a method. If I asked him how he’s doing it he would say I practise, asking my dad for guidance and watching the other kids on my team.

‘Embedding improvement in the NHS means clarity of goals and a method for learning. That’s the whole of it – that’s everything.’



Professor Berwick’s assertions are hard to argue with, but how does the NHS actually do all of this?

‘For Nathaniel it’s a given. As long as he’s a healthy kid in a family and has time and space he can do it. But when you’re trying to get a patient through surgery or change local patterns of morbidities there’s not only one single person who could do it.

‘The answer to how we embed has to be about relationships and interaction as opposed to doing it yourself. It’s difficult because clinicians are trained in individualism – there’s a bit of unlearning about the crucial factor of interdependency.’

For Professor Berwick healthcare expert Tom Nolan’s assertion that ‘for large-scale change you need will, ideas and execution’, rings true. And that is likely to mean major changes would be necessary in the mood, morale and operation of the
health service.

He said: ‘This is key for the NHS. We all have to want to hit the ball far – we have to do it together. Shared intent and will [is vital].

‘Will building comes from two sources: discomfort and hope, and both matter. There has to be a sense of, this can’t go on, and also a sense that wouldn’t something else be wonderful.’



For the modern health service – a battered and bruised operation used to so much change and so much chaos – this may well be the most difficult area. How can frontline clinicians used to sprinting just to keep services running be expected to think of something better?

But Professor Berwick said the vanguard projects – pilot schemes for new models of care running around the country – and some of the early efforts of the more successful sustainability and transformation plan areas and accountable care systems suggest clinicians and managers are already doing just that.

After a whirlwind tour of some of the most impressive and innovative healthcare areas of the country, Professor Berwick said relationships were ‘evolving’ and outcomes could improve as a result.

He said: ‘As we go around England looking at the NHS GP and specialty relationships are changing thrillingly. People are coming together in ways I find very impressive.’

Quality improvement should be an end in itself in the NHS, but with financial gains to be made it becomes even more important. It is vital that leaders at all levels find the headroom, finance, and will, to put it at the top of the agenda.

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