I spent much of last week ensconced in the gigantic shed that is the ExCel Conference Centre in London’s Docklands where three events – the BMJ/IHI International Forum on Quality and Safety in Healthcare, the Health Foundation-sponsored Improvement Science Symposium and the Department of Health’s Safety First event – were held. So, what were my take-home messages from this week of frenetic riverside activities?
It is always good to hear a Tory Secretary of State make an impassioned speech in defence of healthcare free at the point of use, available for all regardless of the ability to pay. So I liked Jeremy Hunt’s defence of what he referred to as 'socialised medicine' at the Safety First event, in response to Republican criticism of Don Berwick in the USA.
More importantly, I got a sense that having attended the event in person and having listened to Don Berwick’s compelling and passionate speech, Jeremy Hunt was beginning to 'get it' when it comes to patient safety. As a result I feel the effort the Foundation is putting into the Berwick Committee, with its emphasis on the safety measurement agenda, is worthwhile.
Hearing positive reports from the improvement science event I detected a growing connection between the science and the practice of improvement: willingness for people to have their ideas and schemes challenged, greater thirst for evidence and a greater prominence for academics with something practical to say.
At the last two International Forum meetings I had come away with the sense that there was nothing particularly new for me. They had both felt 'same old, same old' in both people and ideas. That was not my impression this time.
I was blown away hearing of Devi Shetty's achievements in heart care and of the Aravind Eyecare experience. The energy, passion and sense of achievement from these two Indian players was a wake up call for us in the complacent West. There were also plenty of examples of how the entrepreneurial utilisation of new technology was transforming the relationship between citizens, patients, services and even pharmaceutical research.
That said, where were the CEOs, medical directors and directors of nursing? The ones I spotted were still just the enthusiasts, not the mainstream. I attended part of the CEO's day event and, while it is always a privilege to hear some of the leading US QI big hitter CEOs and to sit around the table with Salford’s David Dalton, where were the rest? Is improvement just a sideshow for interested enthusiasts and not yet part of mainstream NHS management?
The biggest take home for me from the CEOs' session was the importance placed by Gary Caplan, CEO of Virginia Mason Medical Center (who has been a world leader in QI for almost 20 years) on the critical importance of boards and especially board governance.
Gary spoke of the pernicious effect of poor and complacent boards but also of the much neglected role good boards can play. At his board meetings patients are always invited to share their stories in person. The board sees the management response to all complaints. On average the board rejects management’s response to about 10% of them for not being thorough enough, compassionate enough or for not being able to guarantee that the problem will never happen again.
The importance of boards was reinforced by Robert Francis. When asked what the two worst aspects were of what he had found, he replied: the attitude of the board and that of clinical professionals at the trust. The corrosive effect of a board in continual denial, despite internal and external evidence to the contrary, was truly shocking (this mirrors something of the findings of the Epstein research which we funded about the dangers of board complacency).
Francis’ report – disappointingly for me – pulled its punches when it came to criticism of medical behaviour. Yet in his speech he was harshly critical in his comments about senior medics who turned their backs on the disgraceful care being delivered under their noses. Hearing of the shortly-to-retire physician who refused to stand up and be counted because of fear of losing the opportunity of a clinical excellence award, was the one time in the week I felt really angry.
Finally, I found myself frequently asked to explain the new system in England both to those from abroad and those in the NHS. In turn nobody could provide me with a coherent statement of the role going forward of markets and competition, of clinical commissioning groups, of NHS England viz-a-viz the Department of Health, of academic health science networks, of clinical senates… need I say more?
Stephen is Chief Executive of the Health Foundation, www.twitter.com/THFStephen.