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I agree with Don

January 31, 2015

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The week before last I had the chance to see one of my healthcare heroes in real life.

I have been, for a long time, a great fan of the writing of Don Berwick.  Sometimes when you see, in the flesh, people whose work you admire on paper they can disappoint but in Don’s case nothing could be further from the case.  In addition to the interest and intellectual coherence of what he had to say, one saw at first hand the charm, humility and great compassion which makes him rightly, one the great healthcare thinkers in the world.

When I first came across Don’s work when I was on an MBA exchange in Boston in the late 1990s, it was all about quality and how the techniques of workforce engagement, scientific enquiry and Total Quality Management could be applied to improve the quality of the delivery of healthcare.  He’s still interested in this and I remain convinced that these approaches are the heart of successful improvement in healthcare.

However I was struck that in nearly 18 years that Don’s interests have broadened to include a more fundamental critique of the shape of healthcare systems.  He raised a number of challenging points which resonated with many of the issues we are currently dealing with in the NHS in this country.  At the heart of what he had to say was the idea of the triple aim and the challenging objective that healthcare systems have to simultaneously deliver improvements in quality and experience, gains in population health which will ultimately reduce or change the shape of future demand and  a reduction in per capita costs.

Four points from Don’s talk stood out which were particularly relevant to current healthcare debates in the UK .

The first was the need to reorientate our view of health away from a focus on illness to a broader objective of wellbeing.  This, for me, is a fundamental issue which requires us to rethink our paradigm of healthcare and to ignore the flawed division between physical and mental health.  It would  mean a significant shift in our priorities, for instance towards alleviating untreated mental distress, to addressing issues which had the largest impact on lifetime chances and happiness  and to maximising the chances of a good death as well as those of extending life.  For me it means that our societal values must be the master of setting healthcare priorities not technological development, important though that this is, nor commercial or organisational advantage.

The second point was to stress that healthcare interventions account for only a small proportion of the improvement we have achieved in life expectancy and other health outcomes.  This is not to attack medicine.  As Don highlighted it is an enormous achievement, for instance, that in his lifetime as a practising paediatrician, leukaemia has changed from a disease from which children generally died to one which the majority survive.  It is, however, a request for humility and for the need to refocus more of efforts on the causes of and not the presentation of ill health.  It means we should give much more focus to public health which, even in my lifetime, has made some striking achievements whether in the fields of reducing smoking or improving road safety.  Tackling issues such as obesity, the impact of alcohol abuse (and the often untreated mental distress which lies behind it) or the legacy of childhood maltreatment should be at the very centre of health policy, the research agenda and queue for financial investment.  As the most effective public health strategies demonstrate, success will need more than moral exhortation.  If we don’t take action it is clear to me that our commitment to universal health care will be unstainable.

The third point was about waste within the healthcare system.  While most familiar with the evidence in the US, Don’s assertion was that the level of waste within the UK healthcare similar was probably of a similar proportion (around a third of total costs) despite a lower level of spend.  Don identified 6 categories of waste.  For some, such as fraud and abuse, individuals are culpable but most of the rest are functions not of individual action but more of system characteristics.  Three stand out: overtreatment, failure to co-ordinate care and failures in care delivery.  These are all recognisable issues for anyone working in initiatives to improve the integration of care but are from easy to crack in ways which deliver significant savings in the cost of healthcare.  Overtreatment is a particularly challenging issue.  It relates, as I have highlighted above, to our philosophical understanding of the purpose of healthcare but it is also encouraged by payment systems and by a system dynamic which is focused on avoiding practitioner or organisational risk rather than securing well-being.

The final point was the most striking.  As well as being a healthcare practitioner and leader Don had attempted in 2014 to stand for the Governorship of Massachusetts.  From that perspective he highlighted the issue of “confiscation”.  In an economic environment where we can no longer, in western societies, afford all that we might wish to do improve our public services, there is a danger that we allow healthcare, in its narrow sense, to confiscate an increasingly dominant share of what we are able to spend on public services. In the last 15 years health care is the only aspect of spending in the Massachusetts State Budget which has shown an increase.  We see a similar trend in the UK where politicians are prepared to prioritise healthcare at a time where virtually all other areas of public spending see significant reductions.  This raises two problems.  First a wider concern that healthcare confiscation distorts our societal priorities at the expense of issues such as education, economic infrastructure or welfare.  Secondly, though, that healthcare undermines its own effectiveness by confiscating resources from the other interventions which have an immediate impact on the demand for or efficiency of health services.  The impact of major cuts in social care, over the last few years, make this point very clearly.

There is much in Don’s analysis of course which matches the direction for the future of healthcare set out in the 5 Year Forward View.  My concern is that, as Don’s talk powerfully reminded me, these issues require a much more fundamental rethink of our model of healthcare and societal priorities than perhaps  some players and commentators have assumed. To use a widely quoted image – the river has moved, we need to do more than rebuild the bridge.  We may not even need a bridge.

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