The Real Don Berwick
Consider this –
…[F]or many patients the most basic elements of care were neglected. Calls for help to use the bathroom were ignored and patients were left lying in soiled sheeting and sitting on commodes for hours, often feeling ashamed and afraid. Patients were left unwashed, at times for up to a month. Food and drinks were left out of the reach of patients and many were forced to rely on family members for help with feeding. Staff failed to make basic observations and pain relief was provided late or in some cases not at all. Patients were too often discharged before it was appropriate, only to have to be re-admitted shortly afterwards. The standards of hygiene were at times awful, with families forced to remove used bandages and dressings from public areas and clean toilets themselves for fear of catching infections.
These conditions caused the deaths of an unknown number of patients. It may sound like a Nazi concentration camp or a third-world “failed state” like Yemen, but it wasn’t. It took place in one of the most advanced industrial democracies in the world.
What should happen in such a situation? Should the facility be closed? The staff fired? Management arrested and tried for manslaughter? At least sued for malpractice? Would it make any difference to you if it was a private or a public facility?
In fact the quote above was taken from a press release announcing the “Final Report Of The Independent Inquiry Into Care Provided By Mid Staffordshire (England) NHS Foundation Trust.” The 500-page report was mandated by the House of Commons and chaired by Robert Francis QC, who was quoted as saying –
It is now clear that some staff did express concern about the standard of care being provided to patients. The tragedy was that they were ignored and worse still others were discouraged from speaking out.
Management knew what was happening, but failed to correct it and even suppressed any discussion of the problems.
Again, what should be done?
Enter Don Berwick.
Dr. Berwick was brought in to chair another committee — the National Advisory Group on the Safety of Patients in England, which issued another report and recommendations for action.
Berwick’s report is a complete whitewash of the situation. Here are a few of their observations and my comments.
Let’s start with Berwick’s personal letter to “Senior Government Officials and Senior Executives of the Health Service.” He writes –
You are stewards of a globally important treasure: the NHS. In its form and mission, guided by the unwavering charter of universal care, accessible to all, and free at the point of service, the NHS is a unique example for all to learn from and emulate.
Good grief, could he be more gushing, even in the face of glaring and criminal incompetence? No one on earth wants to emulate the NHS. Not one nation is trying to replicate the British system. It is the laughing stock of the world. The things about it that Berwick admires are the very things that made this atrocity inevitable as we will discuss below.
Patient safety problems exist throughout the NHS as with every other health care system in the world.
So, it’s no big deal, just the way things go. Get used to it.
NHS staff are not to blame — in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.
NHS staff are not to blame? Who developed the procedures, conditions, environment and constraints? Where is the procedural rule that told the staff to let people lie in their own feces and urine? Who decided to leave food and water out of the reach of the patients? What kind of monster would step over a suffering patient and do nothing? Would Don Berwick be so sanguine if these things happened in a private hospital? Of course not! Heads would roll. But since it is a government hospital, no one is to blame.
In some instances, including Mid Staffordshire, clear warning signals abounded and were not heeded, especially the voices of patients and carers (sic).
So people ignored the abundant “warning signals” and those people are also “not to blame”?
The system must…abandon blame as a tool and trust the goodwill and good intentions of the staff.
What goodwill? What good intentions? If Ford built defective cars that killed hundreds of innocent people, would Don Berwick insist that we “trust the goodwill and good intentions of the staff?”
Many people probably died from avoidable causes, and many more suffered unnecessary indignities and harm…(but) without ever forgetting what has happened, the point now is to move on.
Yes, move on. Nothing to see here. No one is to blame. No one is accountable. “Many people probably died from avoidable causes” and that is really sad, but let’s “move on” to happier topics.
Some of the recommendations are contradictory. Berwick’s commission says that everyone involved in the system must be committed to constant improvement and patient safety, but it also says –
(The NHS should) ensure that responsibility for functions related to safety and improvement are vested clearly and simply in a thoroughly comprehensible set of agencies, among whom full cooperation is, without exception, expected and achieved.
So, on one hand everyone must be involved, but on the other, it is the responsibility of a limited number of agencies, allowing everyone else to say, “Sorry, that’s not my job, it is the work of the Bureau of Patient Safety.”
Most of the report is a long series of self-serving platitudes about continual improvement, life-long education, focus on the patient, and so on. It insists that patients are central to the mission, but even this is contradicted by the make-up of the commission itself. The appendix notes that –
The Committee assembled was dominated in a majority by scientists — experts in organizational theory, quality improvement, safety and systems — and with a healthy minority of people currently in management positions within the NHS in England.
Where are the patients who are supposedly so central to the whole shebang? Not worth including, I guess.
And here is the real problem with the NHS. Like the commission itself, patients are an afterthought. They have no power, no authority in the NHS. The entire system is based upon the idea that well-meaning experts will do things for (or to) supplicating patients who get their services for free and have no choice in what they get.
But the current scandal shows that these experts are not always well-meaning or even competent. What happens to the hapless patient then? They are left to lie in their urine-soaked beds with food and water out of reach. There is no recourse, other than to “move on.”
Without patient empowerment, there is no “system” that can prevent such abuses. We can implore the experts to be caring and competent all we want, but some will not be and it is impossible for committees to police every action by every “caregiver.” And if no one is ever “blamed” for any wrong doing, it is futile to even try.
Another excuse provided by Berwick’s committee was recent budget cuts and resulting staffing shortages. Faced with such shortages, what is a hospital to do? Well, it might have requested that patients make up the difference. It might have charged patients a small portion of the costs, maybe $10 a day, $25 a day, whatever it takes to avoid the staffing shortages. I expect patients would have gladly paid such a fee to avoid the humiliation, pain and even death they experienced by getting their care for “free.”
But such a remedy would have violated Dr. Berwick’s devotion to the NHS’s “unwavering charter of universal care, accessible to all, and free at the point of service.” So, political ideology trumps all else. Sure, patients may suffer, but they suffer for free and we experts can pat ourselves on the back for being so caring.
I appreciate recognition of the dichotomous treatment of public and private failures. You are right on target to point out that private failure of a much less severe nature would engender a much more vehement reaction.
When the public sector is to blame, we are all at fault, because we are all it’s “owners”. This is the fundamental flaw of public ownership, it results in no accountability.
“Yes, move on. Nothing to see here. No one is to blame. No one is accountable.”
No one can be accountable, or else we are all accountable.
I know that it wasn’t my fault!
“Sorry, that’s not my job, it is the work of the Bureau of Patient Safety.”
You are right, JD. The buck can always be passed without thinking that you’ve shirked your responsibility. Nobody thinks they did anything wrong and, in reality, nobody probably did do anything wrong. The system is what is wrong. That’s why this idea of every person being committed to high-quality is ridiculous.
“The system must…abandon blame as a tool and trust the goodwill and good intentions of the staff.”
This is laughable. I think the people who work for NHS are probably fine individuals, this is a matter of incentives. If we rely on goodwill, successful service will be spotty at best.
There is no substitute for the free market. When patients are consumers and when the choice of providers is based on quality and price atrocities like this result in the offending institutions going out of business. Excellent article.
“Where are the patients who are supposedly so central to the whole shebang? Not worth including, I guess.”
When you aren’t serving someone else, you are serving yourself. Public institutions like NHS serve themselves.
“Without patient empowerment, there is no “system” that can prevent such abuses. We can implore the experts to be caring and competent all we want, but some will not be and it is impossible for committees to police every action by every “caregiver.” And if no one is ever “blamed” for any wrong doing, it is futile to even try.”
Nutshell.
The Berwick report brings to mind this blanket statement by Paul Krugman (frequently quoted in James Taranto’s WSJ column):
“In Britain, the government itself runs the hospitals and employs the doctors. We’ve all heard scare stories about how that works in practice; these stories are false.”
“Sure, patients may suffer, but they suffer for free and we experts can pat ourselves on the back for being so caring.”
I don’t think that anybody is trying to pat themselves on the back, they earnestly care about other people. NHS has some flaws, but the ideal of universal coverage is a noble one.
I don’t disparage people who care about others, but money would be much better spent through privately funded health care services that donate to the needy. There is nothing wrong with charity, but there has to be accountability.
Then why are there so many uninsured, suffering people? Why aren’t free markets fixing this?
First of all, there will always be some uninsured, suffering people, that is a byproduct of choice, you get to make the decisions that direct your life. But, to answer your question, we don’t have a free market now, we have a government-directed system that crowds out private investment. In the absence of government, if people needed care, supply would rise up to meet it.
Almost entirely correct, but there is one qualification: America does have A free market in health care, it’s just very small compared to the third-party payer/state directed system. Cash-only doctors, hospitals that offer real prices, insurance policies that put cash in the hands of patients – these are some of the core components of a free market in health care, and as the state-directed system continues to crumble (think public schools) the alternative will (hopefully) flourish (think private schools, homeschooling, private tutors, etc.). Just the other day I wrote up a web site that will help find real prices for self-pay patients seeking imaging services, typically at a fraction of the list price: http://theselfpaypatient.com/2013/09/17/save-on-medical-web-site-offers-real-transparent-pricing-for-self-pay-radiology-patients/
Sites like this, and companies looking to get out from under state direction and actually innovate and provide value to customers are sprouting up all over the place. So while you are largely correct about the dominance of the government-directed system, there is an alternative!
Sabal,
How do you know they “earnestly care?” Maybe they are just punching the clock. How caring can they be if they fail to give patients food and water?
The “ideal of universal coverage” may be a noble one, but the reality seems to be quite different.
There is no accountability without meaningful choice.
The NHS is much better if you’re willing to pay cash to jump the queue. But, then again, anytime you can vote with your feet and deprive an institution of money, it becomes much more accountable.
So the answer is to eliminate government facilities and change to private payment?
Use the following link to check ratings of nursing homes/skilled care facilities in California. Click on those rated one star which are those facilities where you are apt to find compromised conditions similar to those described at Mid Staffordshire. Just try to find a one star facility that is not owned by a private, for-profit corporation. Then try to find a government-owned facility that is only one star.
http://www.carepathways.com/nhg-state-CA.cfm
At least the British recognize the problem and are doing something about it.
Crowding-out.
Are they “doing something about it,” Don? Looks to me like they are whitewashing the problem if they refuse to hold anyone accountable.
If you were evaluating those nursing homes, would you “abandon blame as a tool and trust the goodwill and good intentions of the staff?”
A very succinct video (8 min) by Milton Friedman at the Mayo Clinic explains how this comes about under socialized medicine. http://www.youtube.com/watch?v=VPADFNKDhGM&feature=related
I am seeing this more and more in dealing with hospital executives in charge of developing ACOs and the same from private insurance executives. To them, the spreadsheet is the reality. They have no contact with actual care so they view “quality” by proxy, i.e., Press-Ganey scores, or compliance “metrics” with “evidence-based medicine”. The spreadsheets are then presented to the staff as “feedback”.
The providers then become slaves to creating the proper numbers. Usually you can create quality metrics or give good care, but nobody has time to do both. There is a heavy penalty for not collecting the metrics data… not so much for failing to answer the patient’s call promptly.
The HITECH act of 2009, contained in the ARRA, pushes this as much or more than Obamacare does.
Rodney Dangerfield used to tell a story, “I saw my doctor and he took an X-ray. He said the X-ray showed I needed an operation. I couldn’t afford the operation so I slipped him five bucks to touch up the X-ray!
in his defense, he did say he loved loved love the NHS. And we all know how blind love can be
I have never been able to understand why politicians listen to professional bureaucrats like Berwick, even hire thme to run things for them, and never, ever ask the docs who are actually taking care of patients as to what THEY think should be done, and even on those rare occasions when they DO ask, pay absolutely no attention to what the docs have to say……
Due to limited resources and personnel to distributes those resources, there have to be some that do without or are inconvenienced. Otherwise,everyone falls under the lowest common denominator principle. Under the confines of the mandates of Obamacare, what was the exception, even in areas with the scarcest resources, will become the norm.
The flaws of England’s NHS have long been known, but it has been shielded from public attention by their media.
Now we can all lament the failure of our government to be sufficiently alert to Berwick’s love of the NHS when he was helping prepare Obamacare. Oh, they
were?!
The comment about AO’s and measurement is entirely correct.
Wanda Jones,
having recently been in a private hospital with generous staffing of kind, attentive people.
SF
Yes, NHS clearly poor system. Only covers 100% of population and costs about 40% of what ours costs.
With significantly poorer outcomes…oh, they live longer?
Well, their waiting lists are a huge problem.
Oh….my kids had to wait 4 months to see a dermatologist here?
Right, poorer quality care.
Oh….what did the Las Vegas Sun discover about care in Nevada? 3,689 cases of preventable harm in 2008-9 resulting in 356 deaths.
And wasn’t it John Goodman who published a 2011 article suggesting that 187,000 Americans die annually due to harms from our medical care system?
Good bullying of Berwick. You clearly are in the right.
I am bullying Don Berwick? That is Orwellian Newspeak. How can I bully Berwick when I have no power and he has lots of power? Perhaps you are one of those NHS managers who intimidated staffers from criticizing what was happening at Mid-Staff. We mustn’t ever be critical of the people in power, eh?
The Liverpool Care Pathway is the tidy way the NHS does away with the “useless eaters.” Follow the algorithm and the patient dies over the weekend.
In the US, Medicare pays 100% of the cost of hospice care. There are 100 new hospice companies that have arisen in New Jersey alone. They come to our office to vie for referrals. We get free pens and stationary.
Now–combine that with physicians selling their practices to hospital systems and no longer being allowed to think independently.
Employed physicians will be asked to choose between the Oath of Hippocrates and their better judgment OR the diktats of the hospital administration and their jobs.
Ethical physicians will hold out as long as they can, but the handwriting is on the wall.
An insight to Obama”Care?”. Remember – The Road to Hell is paved with Good Intentions.
I spent a great deal of time studying the Mid-Staffordshire debacle, having written extensively on the subject. The idea that individuals dependent upon a bureacracy for their career advancement and livelihood will stand up in defiance of protocol and call out their supervisors and upper management for criminal negligence is ridiculous, and for them, economically suicidal. The system is at cross purposes to the best interests of the patient in a socialized model. Collective goals cannot be derailed due to the inconvenience (even unto death) of an individual. This is the fatal flaw in the NHS and all other models of collective medicine, and permitted no other outcome in the Mid-Staffordshire case. Bureacracies will not reduce themselves when resources grow scarce, so the quality of service bears the brunt of cutbacks. As far as the previous commenters blathering about NHS successes in outcomes, one really should consider the reports given by the Mid-Staffordshire trust management all the way up to, and even a bit beyond the breaking of this particular scandal. As would make a Maoist overseer proud in mid-20th century China, the patients were reported to be happy, healthy and well pleased with their care at Mid-Staffordshire. And regarding those poor souls who died from appalling neglect, well, lets just leave them out of the numbers shall we? Wouldn’t want to prejudice our report would we? Had it not been for relentless agitation on the part of abused patients families, Mid-Staffordshire would still be killing people while sending glowing reports to the Home Secretary.
Joe, your insight into the mentality of workers in a socialist health care system is spot on. Obedience is expected and those who oppose the system are dealt with by being shamed or fired.
This is why we in the US must vehemently oppose a centralized health care system as it will only lead to greater bureaucracy and less actual medical care. Shedding light on these abuses is our major weapon, and coming up with an alternative non-government way to care for the poor will be essential.