Don Berwick, a North American fan of the NHS and critic of the wasteful US healthcare system, urges us to create ‘ Era 3 ’ of modern medicinei. His arguments have not only appeared in a US academic publication, the Journal of the American Medical Association, but also in a presentation to the King’s Fund on improving the quality of NHS care, in February 2016 he offers a manifesto for the NHS which differs from the usual exhortations to integrate, collaborate and become patient centred. Berwick describes the history of modern health care systems in terms of three eras.
Era 1 was the period of noble, beneficent, self-regulating professionalism that powered the NHS assembled by Labour in 1948. In the compromises needed to launch the new health service, the political class conceded to the professions the authority to judge the quality of their own work.
Era 2 began when the variations in the quality of care; the injustices and indignities inflicted on people because of class, gender and race; the profiteering and the sheer waste of Era 1, became inescapable. Era 2 introduced accountability, scrutiny, measurement, incentives and market mechanisms. As Berwick puts it, “The mechanism of Era 2 is the manipulation of contingencies: rewards, punishments and pay for performance”. Labour contributed to the consolidation of Era 2 during the Blair/Brown governments but the Era’s origin is in the late 1980s with purchaser-provider split, imposition of contracting, the promotion of evidence based medicine and the industrialisation of the NHS.
Era 2 has promoted discomfort and defensiveness amongst NHS staff, and feelings of anger, of being misunderstood and of being over-controlled. Managers and the Department of Health in turn become suspicious, feel resisted and can become either aggressive (the culture of bullying) or helpless while their political superiors invest more and more in “ravenous inspection and control”.
The conflict between the competing and incompatible drivers of Era 1 and Era 2 diverts attention and resources away from improving and redesigning care, according to Berwick. The question for policy makers is how can the conflict be resolved productively, and how can Era 3 be synthesised? In other words, what would a modern care system look like?
Berwick has some suggestions, but before considering them we should think about two things that are specific to our situation.
Firstly, those most publically defending the NHS are mainly defending Era 1. They want to return to a time before the mechanisms of Era 2 were introduced to the NHS. They are deeply conservative in attitude and emotionally are prone to shroud-waving when any change is proposed. Catastrophe is never far away, and conspiracies abound. They are reductionist and tend to have a narrow focus on ‘privatisation’ rather than a broad view of Era 2’s mechanisms. Far from being a solution to the conflict between Era 1 and Era 2, they are part of the problem.
Second, the funding of the NHS is so constrained that its normal functioning cannot be guaranteed. The apparent £22 million budget shortfall in England by 2020 is too big to be corrected by increased productivity, new ways of working, pay restraint and reductions in expenditure on medication. The government’s expectation that squeezing the budget will stimulate higher productivity and creativity in work organisation is not shared by most of those running or working in the NHS.
This is not to say that change is impossible, and some will indeed occur. Nevertheless it seems clear that the financial targets will not be reached. Failure to meet targets is more likely to increase the bullying that is so widespread in the NHS than to reduce it. Continuing reluctance to fund adequately the parts of the care system outside the NHS will just make everything even worse.
Moving from the current underfunded and unstable care system to Era 3 will require solutions to the problems of funding and accountability, but based on a different approach.
Berwick has nine suggestions for helping Era 3 into being:
1. Stop excessive measurement
2. Abandon complex incentives
3. Decrease the focus on finance (once the quality of care is optimal, costs will fall into place)
4. Reduce professional prerogative
5. Recommit to improvement science
6. Embrace transparency
7. Protect civility
8. Really listen (especially to the poor, the disadvantaged and the excluded)
9. Reject greed (it erodes trust)
How can these ideas work for the NHS? Berwick’s experience is based on US medicine, where the problems are starker than in the UK. But the other side of that coin is that the NHS has many people in it who want to make these kinds of changes. Could Labour come to their aid? How do the suggestions fit with the Labour vision of Whole Person Care?
Berwick’s Era 3 is driven by the escalating costs of US health care and the terrible waste of money in their fragmented and consumerist system. What Berwick wants is a single payer system, but we have that already and our funding problem is shortage not over-expenditure. Increasing the funding of the NHS to allow normal function to be restored will be necessary, but how will Berwick’s other aims be reached?
Stopping excessive measurement and abandoning complex incentives within a light-touch management approach would be welcomed, partly because these changes might foster professional prerogative and favour vested interests by reducing scrutiny and inspection. Would central funding and a better definition of what the health and social care systems have to do, combined with decisions by elected local government on how it is to be done, be sufficient to check professional prerogative?
Would our Era 3 system form around a structured response to societal changes like population ageing and rising consumerism? Will it depend on full engagement of citizens if the NHS is to be sustained, as argued by Wanless in 2002? Can we resist consumerism but favour personalisation?
Would Era 3 see the end of the primary/secondary care division? Would it see an end to commissioning as we know it? And would the emergence of local care systems (perhaps based on Sustainability and Transformation Plans) streamline care for reasons of outcome not cost? Would the Treasury accept that this might slow the growth in NHS costs but not save money, as such?
The Coalition government started by insisting on policy based on patient outcomes, but soon had that idea lobbied out of them. Were they onto something important, like a counter to medicalisation and a force for evidence-based policy? Perhaps policy cannot be based solely on patient outcomes because we cannot measure the totality of them – but things like the National Service Frameworks, which were based on evidence, were a good thing, even if that thought takes us back to (the softer end of) Era 2.
Civility really does need protection. Bullying is endemic in the NHS. We know that “policies” can be brilliant on paper but do not necessarily get implemented, and that working relationships can be more significant than structures or laws. How would better relationships be stimulated?
Staff satisfaction correlates with patient satisfaction, so investment in staff well-being and genuine staff engagement really do matter. But probably the majority of Trusts are poor in their treatment of their staff – the junior doctors’ fears about being exploited are well-grounded – and whistleblowing provokes clear threats to the whistler’s career. Home care staff are trapped in a system of zero hours contracts and 15 minute visits with little or no training or development. Will more pay and better conditions be enough to raise morale and satisfaction?
Rolling out best practice after proper benchmarking and a detailed independent evaluation (an Era 2 approach) does not appear to work. What will? What should be measured and what local variability is tolerable; who decides?
Inertia is deep-rooted in the functioning of the NHS. The rationalisation of paediatric cardiac surgery urged in 2001 has yet to happen, whilst discharge planning and alternatives to A&E have been worked on for decades yet remain problematic. Recommitting to improvement science sounds like it belongs here, but in practice what will it mean? Should we try to solve the discharge-from-hospital problem by preferentially funding the growth of 24/7 ‘hospital at home’ services rather than traditional hospitals? What happens when evidence throws up the “wrong” and deeply unpopular answer?
Claims have been made about the transparency within the NHS and much data appears to be available, even to private companies. Yet anyone trying to get information out of the NHS (usually through Freedom of Information) experiences obstruction – often based on spurious claims of commercial confidentiality – or is simply ignored. Who owns the data? Who kite-marks its value? How can parts of the care system outside the public sector brought into a transparency framework?
Sadly few if any other specialities followed the example of transparency by the cardiac surgeons (after Bristol) and put outcome and mortality data freely into the public domain. What will overcome professional reticence; the Royal Colleges?
As for really listening, the NHS is especially bad at this. Can it really move to shared decision making? Can it accept the view that patients and communities are assets not a nuisance? Can it embrace genuine processes of engagement and consultation?
Finally, rejecting greed. Will anyone dare disagree? Not if it is put so pejoratively, but the medical profession in particular plays Knights and Knaves with the NHS. In Knightly mode it asserts its professionalism and commitment to patient care, with unpaid working beyond rostered hours as evidence. In Knavish mode it points out that its’ altruism must be rewarded if it is to continue. Hence the profession’s belief that NHS consultants deserve Clinical Excellence Awards (CEAs, the new name for “merit awards”). Hence also the view among junior doctors that the NHS will be saved by getting the price of Saturday afternoon working just right.
These and other questions need credible answers if the voters are to commit to significant additional funding to support a modern health and social care system. Can Labour find the answers and use them to introduce Era 3 with the same zeal and determination that brought in Era 1?
Steve Iliffe & Richard Bourne 12/7/16