McKee, Martin

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M. McKee

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Improving the safety of patients in England

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McKee, M (2013) Improving the safety of patients in England. BMJ(Clinical research ed), 347. f5038. ISSN 0959-8138Downloaded from: http://researchonline.lshtm.ac.uk/1130087/Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Creative Commons Attribution Non-commercial No Derivativeshttp://creativecommons.org/licenses/by-nc-nd/2.5/Improving the safety of patients in EnglandBerwick’s report should be required reading for everyoneMartin McKee professor of European public healthLondon School of Hygiene and Tropical Medicine, London WC1H 9SH, UKThe health service in England has been subjected tounprecedented scrutiny in recent years, with the Francis Report,1Keogh Review,2 and now a report from a panel chaired by theAmerican patient safety guru, Don Berwick.3 Although all dealwith the same problem, the reports are quite different. WhereasFrancis, a lawyer, produced a document stretching to more than1700 pages, with 290 recommendations, Keogh and Berwick,both doctors, wrote concise analyses, with Berwick’s amountingto only 46 pages and 10 recommendations. For those unwillingto read even that, Berwick adds three letters, to seniorgovernment officials, to NHS staff, and to the people of England.Each emphasises four fundamental principles, that quality andsafety must be placed above all else, that patients and carersmust be empowered and heard, that staff should be developedand supported, and that there should be thorough andunequivocal transparency.Unfortunately, despite its brevity, the immediate responsessuggested that those commenting on it had failed to read itthoroughly. The health secretary claimed that it supported thegovernment’s reforms, whereas patient groups believed that itignored some of their key demands.4 Neither conclusion isjustified. This is a report whose every word requires carefulstudy, not superficial scanning.Berwick recognises that healthcare is political, and he wasclearly aware of the current sustained ideological campaign todenigrate the NHS.5 Thus, he states unequivocally that it is a“world-leading example of commitment to health and healthcareas a human right” that should be emulated and that, althoughthe NHS does have patient safety problems, so does “every otherhealthcare system in the world.” He agrees that “big changesare needed” but notes how its “achievements are enormous”and catalogues ways in which it continues to improve. No doubtmindful of how “zombie statistics” were misused to attribute13 000 excess deaths to failings in the hospitals Keoghreviewed,6 Berwick suggests that “drama, accusation, andoverstatement” are best avoided.He shows his independence by challenging the primeminister’sambition of zero harm, noting how patients must often balancethe harms and benefits of treatment. He understands that manyrisks could be eliminated if resources were infinite but knowsthat they are not. He calls for “constant vigilance againstreductions in resources” but also a mature and open dialoguein which trade-offs must be explicit when goals such as costsavings are being pursued.He is emphatic that most health professionals seek to do a goodjob and calls for them to be spared the now too common“generalised criticisms of their intentions, motivations, skill, ordedication.” When things go wrong it may be as a consequenceof wilful or reckless neglect or mistreatment, but this isextremely rare, and when it happens he accepts the need forcriminal sanctions. Much more often the cause will be failingsof the system or human error and “it makes no sense at all topunish a person who makes an error.” Instead, the organisationshould learn from it.This view underpins his approach to regulation, which “alonecannot solve the problems highlighted by Mid Staffordshire”as “in the end, culture will trump rules.” Describing the existingregulatory system as one of “bewildering complexity,” he callsfor a regime run by “true experts” who can “apply thoughtfuljudgment,” a model that seems far removed from the tick boxculture that has characterised the Care Quality Commission. Itis unfortunate that many of the public health professionals withskills in healthcare evaluation have been pushed out of the NHSin the recent reforms. He also reflects widespread concernsabout lack of patient involvement,7 asking whether the conceptof community health councils should be revisited.Berwick’s report has, however, attracted some criticism. Onerelates to his reluctance to recommend minimum nurse staffinglevels. Yet, he shows how the reality is more complex. He knowsthat low staffing levels threaten patient safety,8 noting that amedical or surgical ward with fewer than one trained nurse forevery eight patients, plus one in charge, is likely to increaserisks substantially. However, mindful of the potential for thisto become the norm, he notes how more nurses will be neededif patients are sicker. He states that staffing levels must beinformed by a more sophisticated real time system to ensurethat they match patient needs. This is a warning to thosehospitals saddled with large private finance initiative liabilitiesthat are currently shedding staff.A second criticism is his rejection of a legally enforceable dutyof candour. Again, his words require careful examination. Heis clear that patients have a right to have all their questionsmartin.mckee@lshtm.ac.ukFor personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2013;347:f5038 doi: 10.1136/bmj.f5038 (Published 9 August 2013) Page 1 of 2EditorialsEDITORIALSanswered and that professionals must notify all serious incidents.However, he cautions against the immense bureaucratic burden,as well as the anxiety that would result, if patients had to betold of every error, no matter how minor. He also calls forresearch about how best to communicate these matters topatients.Berwick’s clarity of writing, logical flow, and at times subtlephrasing might lead some to think that he has said little that isnew. But he has put forward a clear vision for a new set ofrelationships between patients and health professionals to ensurecontinuing improvements in quality and safety based on trust,not fear. He has given them a powerful weapon in the fightagainst those who seek to undermine the NHS and denigrate itsstaff in pursuit of ideology or profit. It is now up to them toseize it.Competing interests: I have read and understood the BMJ group policyon declaration of interests and declare the following interests: None.Provenance and peer review: Commissioned; not externally peerreviewed.1 The Mid Staffordshire NHS Foundation Trust Inquiry. Final report of the independentinquiry into care provided by Mid Staffordshire NHS Foundation Trust. 2010. www.midstaffspublicinquiry.com/report.2 Keogh B. Review into the quality of care and treatment provided by 14 hospital trusts inEngland: overview report. 2013. www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf.3 National Advisory Group on the Safety of Patients in England. A promise to learn—acommitment to act. Department of Health, 2013. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf.4 Bosely S. Tough stance on regulation amid Berwick review’s goodwill proposal.Guardian2013; www.theguardian.com/society/2013/aug/07/berwick-review-nhs-regulators-analysis.5 Bourne R. The end of our NHS? Socialist Health Association 2013 www.sochealth.co.uk/2013/03/31/the-end-of-our-nhs/.6 Bosely S. Hospital needless deaths figure “misleading.”Guardian 2013; www.theguardian.com/society/2013/aug/07/nhs-health.7 Calkin S. Exclusive: flagship HealthWatch policy to be ‘watered down’ by amendments.Health Serv J 2012; www.hsj.co.uk/news/policy/exclusive-flagship-healthwatch-policy-to-be-watered-down-by-amendments/5041938.article.8 Rafferty AM, Clarke SP, Coles J, Ball J, James P, McKee M, et al. Outcomes of variationin hospital nurse staffing in English hospitals: cross-sectional analysis of survey data anddischarge records. Int J Nurs Stud 2007;44:175-82.Cite this as: BMJ 2013;347:f5038© BMJ Publishing Group Ltd 2013For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2013;347:f5038 doi: 10.1136/bmj.f5038 (Published 9 August 2013) Page 2 of 2EDITORIALS

Improving the safety of patients in England.

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Improving the safety of patients in England.

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