The Berwick report: why we mustn’t let this opportunity pass

If someone were to ask me why I am doing the job I am, I could pinpoint the reason as an evening in April 2000. At the time, I was Head of NHS Performance at the NHS Executive and was providing the secretariat for one of the Modernisation Action Teams tasked with producing the NHS Plan.

With a stellar group of experts and leaders from across England, I couldn't understand why there was someone from Boston flying in for our next meeting. Ahead of the meeting, he had sent a video to Neil McKay who thrust it in my hand and said 'someone better watch this before he turns up'. That evening I watched Don Berwick's finest IHI National Forum keynote 'Escape Fire'.

As I sat transfixed by a combination of personal narrative, improvement science and allegory, I realised that there was another side to healthcare that, up until that point, I hadn't understood and, from then on, I wanted to be part of.

Thirteen years later, I have had the privilege of being part of the advisory group to Don set up in response to the Francis report.

Back in 2000, Don brought a unique voice to the Modernisation Action Team where he talked of the need to put safety first, the need to support staff with the skills and encouragement to provide the care they came into the NHS to deliver, for leaders to be vigilant about the need to learn from harm and error so that healthcare is a system in continuous improvement. He talked about the toxic effects of losing sight of why we provide healthcare, of when we take recourse to blame and when we fail to understand the system of care we are responsible for.

Looking back, I wonder whether we should have listened harder to Don. While some of the spirit of his philosophy found itself in the NHS Plan, we cannot hide from the fact that, in delivering the much-needed change (to take away the tyranny and fear of long waits for treatment), there have been points where we lost focus and patients have faced a different fear.

Over the years, there have been a number of missed opportunities including the report of the Bristol Inquiry and An Organisation with a Memory. Don Berwick’s report published today is another chance to take action. While many may ask ‘where are the big ideas?’ and many may challenge that it doesn't say anything new, I would reply: isn't that the sad truth? We know, and we have known for a long time, what we need to do to make care safe. Our challenge is to put it into practice.

We need to give up the idea that there are quick fixes, that restructuring and reassigning roles around the system will make a miracle happen. As healthcare provides more possibilities to heal, it presents more opportunities for harm. Safety is the emergent property of every single interaction that happens in healthcare - everyday, every minute.

Only when we recognise that making care safer requires everyone to have the skills they need to apply the science of safety, measures to know when risks may arise and the support to learn from mistakes will we be able to say that we have learnt and acted on Francis.

Improving quality in healthcare isn't a zero sum game. It doesn't have to be financial balance or patient safety. It doesn't have to be speedy access or compassionate care. Throughout the UK, there are organisations that have worked over the past decade to deliver high quality care which is safe, effective and person centred. They have built the skills and context needed to deliver safe care. Let's hope today's report will provide the inspiration and encouragement for others to do the same.

Jo is Director of Strategy at the Health Foundation and was a member of the review group for the Berwick Review, www.twitter.com/JoBibbyTHF