Wednesday, 7 August 2013

Don Berwick Report

Don Berwick NHS patient safety report - will it work?
It will. Though there is a blind spot to watch out. 

A blog from a particular perspective

Don Berwick report 'A promise to learn, a commitment to act, improving the safety of patients in England' has been published ( There is all round praise which is well deserved. The entire report is full of gems of wisdom. As a practising clinicians who also values work life balance, I have still managed to fast read the report, I will read it again in detail. As a student of improvement science I am sure I will learn a lot from the report. I am a fan of Don Berwick, I have heard him speak a number of times and every time I am not only moved but I always come away with great learning. It was one of the cherished moments in my professional life when I shook his hand at the Forum in London in April 2013 and he walked with me to personally introduced me to Sir Brian Jarman.

Don's report is pretty comprehensive as expected, I hope the report will be effective.

The Blind Spot
My problem with the report is not the content, my problem is with the membership of the advisory group. It is elementary in leadership that while what is said does matter, how it is said and who said it really matters more. Why do you think football celebrities endorse non-sports products?

The committee was happy that they were independent.

The advisory group was made up of 17 persons whose expertise is unquestionable. 4 of them were Americans from the Boston-Harvard area; with 3 of the 4 Americans from the same organisation. 12 out of 17 were non-NHS, the 13th was NHS Scotland. No Europeans. No one else from the US aside or instead of this close knit group.

9 of the 17 were women - finally it looks like we are recognising that the half the real world is indeed made up of a gender who are not male, well done. 

17 out of 17 seem to be white. 

Don Berwick is no stranger to England, he is no stranger to inclusive leadership. Don was obviously so dedicated to answering the questions put to him that his human limitations prevented him from recognising that in London when he walks the streets 50% are foreigners, 40% are Black and Minority Ethnic. If Don entered any hospital he may have noticed that about 40% of doctors are from BME origins and in London nearly 40% of healthcare staff are of BME origin and about 10% of this country are from BME backgrounds. Don's report speaks about adequate staffing. Where do you think that comes from? We are hearing reports of urgent recruitment of rota fodder to deal with the A&E staffing crises from countries like India, Don and his committee would recognise Indians are part of the BME group.

The Quality Chasm and Leadership Deficit

Who speaks to whom matters. Constituencies matter. Don is now a politician, he will do well to remember that his country's president won his office on the black vote (though certainly not exclusively on the black vote). If Don looked and did not find an person who has some expertise in quality and safety who also happened to be non-white he should have mentioned that a part of the system failure that he talks about.

The report talks about culture and fear. Amongst the most afraid in day to day clinical practice are BME doctors who face a higher rate of referral to their regulator; they are also thought to have higher rate and higher intensity of sanctions by their regulator. BME doctors also face extraordinarily adverse pass rate in their specialist examinations, unlike in Don's country.

It is not as though the committee did not have a BME connection. It did have a most profound and tragic BME connection. Lisa Richard Everton, a patients' representative on the committee lost her husband Paul Everton due to a lethal overdose at Heartlands. Paul Everton was black. Don would know that in our much revered NHS BME's get poorer health outcomes.

I was actually hoping to have interactions, debates or arguments on the technical aspects of improvement and patient safety issues with Don; I am sure I will in the near future. Instead I am talking about leadership, culture, inclusivity and race. On my initial reading, the report excels and succeeds at the theoretical and technical aspects where the content experts lead by example. The report fails in its operational aspects especially in the context of what the manpower constituency might recognise, mirror and reflect, the report and its committee fails by example

The inability to include or cope with a real mix of normal people is the biggest wall that prevents our already good NHS from achieving even higher standards. A different committee with some persons who have BME style thinking (as opposed to just simply being from a BME origin) in it would not have made any difference in the content of the report, I suspect it might have made a difference in the sincerity and speed of adoption. I am not a race warrior, this blog is not about race, regular readers of this blog would already know that. This blog is about contextual leadership which in essential for success in healthcare.

I remain a fan of Don Berwick, I do not write this in protest or complaint. I write this due to a genuine concern that Don, a person whom I admire and his recommendations should not fail. I write out of a genuine desire that the NHS should cross the quality chasm by overcoming the massive leadership deficit that it faces.

Follow me on twitter @HemadriTweets

PS: I recommend the report. It is up to us, normal NHS staff to make sure that we take this report to the front line and deliver it there to benefit our patients.


Ballismus said...

Excellent, balanced and a very well calculated article. Well done MA Hemadri.

M HEMADRI said...

Thank you Ballismus

It seems this has reached the right places and could be taken into account for the future.

Well worth watching the space.