“A free Health Service is a triumphant example of the superiority of collective action and public initiative applied to a segment of society where commercial principles are seen at their worst”, wrote Aneurin Bevan, the architect of the UK’s National Health Service (NHS) in his collection of essays In Place of Fear. 65 years after its inception, the NHS is still one of the greatest examples of universal access to health care, which is free at the point of delivery, and seen as a fundamental human right—a system many countries are striving for and others are in the process of dismantling in a misguided response to the current financial crisis.
Yet, reading headlines last week, such as “Struggling A&E [Accident and Emergency] units to get £500 million bailout” and “NHS managers to get price comparison website and use Bargain Hunt for inspiration in bid to cut supplies bills by £1·5 bn”, one might be forgiven for thinking that the current Coalition Government views the NHS as a failing bank or business. This stance is one of the most cynical, and at the same time cunning, ways by which the government abdicates all responsibilities for running a health-care system that has patient care and safety at its heart. Rather it expects the system, and in it each trust for itself, to be efficient, cost saving, and financially successful or else it is deemed a failing enterprise. Doctors, nurses, and health workers are readily blamed for the quality of care they provide within these constraints. And the UK’s media obligingly colludes.
Of course, with the new Health and Social Care Act 2012, which came into force on April 1 this year, the Secretary of State for Health no longer has a duty to provide comprehensive health services. This responsibility now lies within a complex system of organisations, such as NHS England and the 211 clinical commissioning groups with their commissioning support units, and regulators, including Monitor, the Trust Development Authority, and the Care Quality Commission. The exact responsibilities are at best complex, not easily understood, and at worst deliberately obfuscated. Who exactly is leading and to what end is even less clear.
The quality of care provided has come under intense scrutiny in several reports and many recommendations have been made since the scandalous failings at the Mid Staffordshire NHS Foundation Trust were fully described in Robert Francis’s report, published in February this year. Since then 11 other trusts with the highest hospital standardised mortality rates have been placed into special measures by the Secretary of State for Health Jeremy Hunt. Such mortality rates, however, can only be used as a warning signal for deeper and more systemic failings. Intelligent fine- grained scrutiny and analysis at local levels is needed. So argues Don Berwick, a US Professor of Paediatrics and Health Care Policy and former adviser to US President Barack Obama, in the latest report Improving the Safety of Patients in England, released last week. How many more reports of this nature are needed before the situation changes, some observers have asked?
Of all published reports, this one is arguably the most pertinent and, if heeded, could make a real difference. It takes, in Don Berwick’s own account, a more philosophical approach and makes very sensible recommendations. The quality of patient care should be placed above all other aims. Blame as a tool should be abandoned. Quantitative targets have an important role on the way to progress but should never displace the primary goal of better care. In the vast majority of cases, it is the systems, procedures, conditions, environment, and constraints the staff face that lead to patient safety problems. The report also emphasises that sufficient staff must be available to meet the NHS’s needs now and in future but leaves it up to the National Institute for Health and Care Excellence to make evidence-based recommendations on exact staffing levels.
The role of Chief Executive NHS England was advertised last week with a deadline of Sept 6 for applications. Astonishingly, the candidate does not have to have experience in, or knowledge of, health- care systems. However, only someone with the calibre, passion, experience, and wisdom of Don Berwick will have the slightest chance of turning around the NHS from its current path to a market commodity to its true purpose of a compassionate, free, equitable, and effective health system with patients’ health, wellbeing, and dignity as its goal and top priority.
Cross-posted from The Lancet with thanks.