Donald M Berwick: clinical leadership of health care reform

I am an optimist. I think enormous improvements
are possible for our publics, the people we serve but only if leaders embrace the very,
very difficult transitions that are necessary to modernise. One out of seven dollars in
the American economy gets absorbed by health care. It means 2 things. One is that it’s
a massive problem to change; turning the Queen Mary is easy compared to taking this immense
ship of technology and moving it toward the needs of chronic illness and prevention in
the communities. A very hard problem. The second part of the problem is economic which
is 2.7 trillion dollars is a ton, now we are at 17% of our GDP, Britain is at what ten
and a half maybe not quite the same proportion but you can sense here in this country the
urgency that is felt. Why is that? It’s because there are other uses for money. In my State
of Massachusetts not a single area of public investment is increased in real terms in ten
years except health care. In America the enterprise of building a new
bridge, if you will follow my metaphor, has fallen dead centre into the worst episode
of political polarisation in the memory. I don’t know the political environment here
as well, there is an under cut in the civility and that I still believe in. Anyway you talk
well so perhaps you discuss well I don’t know but I tell you it’s tough. The English NHS
through the UK as a whole economic pressure a debt in deficit affecting health care, health
care being questioned in terms of the amount of social opportunities it has taken compared
to other public and private sector investments. The public in your case looking at its tax
bill and wondering if it’s getting value for what it’s being charged and a loss of real
conversation in the face of headline news and rhetoric that may not bear a lot of relationship
to the complexity of reality, a confused public wondering what’s going to be lost and a profession
who doesn’t know which way to go is worried. If you want to make something better you have
to decide to do it, you have to have a ‘what?’. That is, you’re going to need to decide to
improvements. Improvements are not automatic. Entropy is automatic, decay is automatic.
To re-organise and be able to grow takes intention so there is a ‘what?’ to an improvement.
Rule 1 then you better have a ‘how?’. I mean yelling at yourself if the tennis ball goes
the wrong place or a throwing your soufflé out and just screaming that it’s a bad soufflé
it doesn’t help, you need to change something, you are going to need a way to change the
recipe. There is a myth about I think that the route science of health care improvement
anyway is economic you know set the carrot and sticks appropriately, put in correct contingencies
and all will be well. I guess most people believe that. I do not. I think that perhaps
a proper structure of incentives sets the stage for improvement but that would work
no more than teaching a child to play the Pathetiques or not on the piano by giving
him cookies when it goes well and hitting him across the head when it doesn’t. That
would be a very depressed child, he would cry, he definitely would not play the Pathetiques
now, you have to teach him how to play the piano and that’s the nature of improvement.
To me it’s a learning process. My colleagues Tom Nolan and John Whittington
in 2008 they came up with the idea that when you are thinking about improving a large health
care system, maybe a hospital or certainly a nation, 3 goals are to be pursued at once
in order to serve society. They called this the triple aim. The triple aim is first better
care, safer care, more patient centred care, better care more aligned with science, or
equitable care, more timely care but say Nolan and Whittington, “Wait a minute why did you
have your heart attack, why did you break your arm, why are you depressed, why do you
have lung cancer?” and the answer is not that you didn’t get health care, health care is
after the horse left the barn, it’s the fix it shop.
The causal system lies outside health care, it lies inside society. 400 per cent more
than in health care that’s actually a number if you take the variance and health status
and you attribute it to different causes say a 100 points health variation 50 will be genes,
not yet that alterable, there’s 50 per cent over, 50 more points well 10 are health care
and 40 are the rest of the causes. So health care is one fourth as powerful as everything
else I could list around nutrition and activity and equity and justice and pollution and stresses
in life and the third per capita cost matters bring it down, bring it down, lower the cost,
better care, better health, lower cost. This became a mission statement at Medicare under
my leadership. When I went there on day 3 I showed this to the 5,000 employees there,
virtual tele-conference and I said this is success for us. I was offered the job of heading
Medicare in Medicaid and turned it down. I turned it down several times because it didn’t
make sense to me to leave IHI and go there given the differences in the job. Then I was
in the atrium, the entrance hall to the Health and Human Services Building in Washington
to be interviewed and I saw this etched on the wall these words from a famous American
Senator Hubert Humphrey, he said the moral test of Government is how it treats those
who are in the darn of life, the children, those who are in the twilight of life, the
aged and those who are in the shadows of life, the sick, the needy and the handicapped. This
is 100 million; this is one out of three of my compatriots of meeting the moral test became
very important to me. I heard last year a quotation I don’t know where it’s from, perhaps
someone can tell me. “We don’t inherit the world from our ancestors, we are borrowing
it from our children.” And when I read the morning papers now I wonder what we are handing
them. I am just showing you the orientation question in a complex environment fraught
with conflict, uncertainty, pressure, you better find your compass whether yours is
the moral test or your grandchildren or the triple aim I don’t know that is up to you
but you individually you England, me individually, my country, better remember why or how makes
no difference. To provide a foundation that is capable of
achieving better care, better health, and lower cost at the same time unless we remember
the changes the way we will be facing a very vicious environment in America. We will be
cutting back on our safety net programmes; we will be taking money away from citizens
through tax dollars or through cuts in their pay because money has to go to health care
benefits. We will be weakening the other investments we want to make with health care dollars like
teaching and research and more than that we are weakening the parts of society that can
benefit a better performing health care, we will weaken museums, we will weaken schools.
The NHS version of this I don’t know. I think from what I have seen through the years structural
problems, your hospitals despite repeated attempts to give power to the primary care
system which wants to keep the patient home. Your hospitals are very much under incentive
to stay rather busy and to make sure that they have less of an incentive to build the
continuity that we need. Patient-centred care well we see Mid-Staffordshire a dramatic example
where apparently cost pressures became dominant and somebody forgot about the returning to
the patient as focus of care, everybody forgot. And you continually re-structure all the time
as if you can somehow find the correct number of agencies and that just isn’t just going
to work people. It’s not the way to get there. Your public I don’t know. Do you suffer in
your public from the more is better theory when that’s not true or the reaction to the
latest headline drives events instead of allowing for strategy?
I don’t think this is a very good time for minor experiments, there is no time left in
a way I feel a sense of urgency for us that going to scale was going to matter. You’re
closer than we are beginning with your solidarity that stretches back to 1948. There is a window
right now and I don’t know whether it is three months long, three years long, it’s not ten
years long and that is for the people who give the care to change the care. I think
it’s possible, could we do it, physicians, nurses, pharmacists, therapists, managers,
executives, boards, leaders of care to say “you know what? it’s on us, it’s on us”. We
must do it and we can do it and we will do it.

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