19th April 2013 

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Is there an echo in here?
News and Comment from Roy Lilley

Relax, the guru is in town.  Don Berwick and his committee have started their hunt for the Holy Grail.  An error free hospital.  I wouldn't wish to appear churlish but it does not seem to be a topic the US is in a position to preach about.  Astonishingly 30% of American patients have experienced a medical mistake.  Nevertheless, it's no reason not to try.   


The cynic in me suggests the Berwick report, which will be based on a review of Francis, will give the Coalition cover for not implementing very much of Francis.  Berwick & Co will produce a slimmer report with fewer recommendations.  Easier all round.  


All this new found interest in quality, safety and excellence results from the performance of a badly run SHA, a rotten Board and an under resourced front line at Mid-Staffs.  I can save Berwick & Co the time and trouble; demand more of the Boards, protect the front-line, fund it properly and make it fun to work there and most problems go away.


There are those who will tell you that quality, safety and excellence (and the three are not necessarily the same) have nothing to do with funding.  They generally tend to be politicians who don't want to give you any more money and the upper echelons of NHS management whose jobs depend on saying 'Yes Minister'.


There is a counter argument that runs; quality is free.  It's true in the sense that if you don't get it right first time 'doing it again' comes with a price.  Failure creates a demand on resource because of 'doing it again'.  It's less costly to get it right.  However, it doesn't save money; it just avoids incurring the additional cost of failure.  A different thing.  So, you can argue, it's not true.  We should say quality avoids the cost of failure demand. 


Quality is deciding what you want and putting things in place to make sure you get it, all the time, every time until you want something else.  Quality is really consistently getting what you want, always - no surprises.


Berwick promises a no holds barred look at what we are doing wrong.  He might like to start in the places that are doing things right.  There are plenty of them.  What makes a high performing hospital?  I'll tell you; an excellent and engaged Board that makes the front-line their imperative.  Boring, isn't it?  Boards and the front-line... it always comes back to that.


What's wrong with Boards?  I know they try hard but fundamentally, they lack talent.  There are about 400 boards running hospitals.  I seriously doubt there are 400 really good chief executives, 400 FDs and I know there are not nearly 2,000 really good NEDs.  There will be local well-intended do-gooders, Councillors, lawyers, magistrates and 'names' but I doubt there will be enough of the calibre and experience, good enough to run an organisation that might dwarf a FTSE 100 company.  One hundred million turnover and 8,000+ staff is not uncommon in the NHS.  NEDs go native and are too easily flattered, bewildered and side-lined.  Few really understand the finances.  Time and time again Medical Directors have failed to direct and Nurse Directors just haven't turned up.


Hospitals can run safely with about 85% occupancy.   Increasingly our hospitals are on Red Alert, some on 'Black'; choc-a-block.  That level of pressure creates an environment where staff are distracted, tired and frazzled.  Unprecedented growth in demand, flat-line funding and a quest for savings is a toxic cocktail.  New evidence in the English NHS is right here. 


Allowing the nurses on the wards to decide safe staffing levels and giving them the budget to manage might be a start. 


Berwick & Co will know in 2002 the Joint Commission on Accreditation of Healthcare Organizations examined more than 1,600 US hospital reports of patient deaths and injuries since 1996. It found that low nursing staff levels were a contributing factor in 24% of cases. 


I doubt Berwick & Co will tell us anything we don't know but his value will be in telling us what some people won't want to know; 'better Boards and protecting the frontline', works.   


Is there an echo in here?


Have a good weekend. 

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