Jeremy Hunt has asked all the English NHS to ‘sign up to safety’. He has been to Seattle to see how it can be done – for it is certainly true that Virginia Mason Medical Centre in Seattle is a remarkable place – and he correctly identifies some key features that lead to success:
- a passionate, unwavering leader
- a crisis that stimulates a whole organisation to commit to ‘never go there again’
- a method (the Virginia Mason Production System) that every member of staff knows and believes in and uses as part of their daily endeavour to improve their job and make things better and safer for their patients.
The Secretary of State seeks volunteers to start the same journey and reminds us of our own past and current failures in the NHS – great incentives to want to be different and to want to be safe.
He is right to point out that it is possible to put the patient at the centre of what we do and build safety into everything our health care system does. He is right to point out that defective care is more expensive than care which is right first time. And he is right to point out that there are many in the NHS who have already proved that the right culture can support continuous improvement, safety, financial good health, happy staff, happy patients and better outcomes.
The Toyota Production System, when applied to health care, does work brilliantly well and is as strongly evidence based in its impact as almost anything we in health care do. Put together with the right vision (an organisation that truly wants to serve its customers – our patients) and with the right behaviours from staff and managers (an aligned culture for quality and success), it is unstoppable. But like every tool it is prone to failure in its use. And acknowledging this part of the evidence base is important in understanding how similar approaches might work in the NHS.
If it were easy, we would all be doing it. And we would have been doing it for a long time. Hands up anyone who tried the Productive Ward, The Productive Theatre or is currently struggling with the Productive General Practice – and despite some successes, has given up? The data sheets staring empty from the walls? The new process having slipped, somehow, back to the old way of doing things? The excuses, grumbles, snide comments and boring cynicism piling up so fast you need to be able to fly to stay above it?
In a recent briefing, the Health Foundation draws attention to the North East Transformation System (NETS) which is following in Virginia Mason’s footsteps. After eight years, what we learned most of all is that it is going to be hard. As John Kotter famously put it, one of the rules of successful change is that the leaders must ‘never let up’ – this is often difficult within our own system where policy initiatives so often grow, wither and die in time with the political life cycles of our leaders
There are other lessons from Virginia Mason that we must also acknowledge. The doctors who found they didn’t or couldn’t fit with standard methods and a transparent culture left: great for one hospital but this would be very destabilising across the whole NHS. Gary Kaplan, the CEO, and his team devised a strategy and then they have kept to it for 10 years or more: fabulous for them but seemingly impossible in the NHS.
Virginia Mason focus on what they do well and don’t provide comprehensive population based services: great for their strategy but always fudged and always locally unpopular for the NHS. In Virginia Mason, one has to be a trained leader in the Virginia Mason Production System to become (or get promoted as) an organisational leader; every year a team of clinicians and managers go to Japan for intensive training: great for them but implausible, at scale, for the NHS. And so on...
We must also acknowledge the limits of national targets. Hands up who groaned when they heard of another ‘vanguard’ programme? Another initiative to sign up to? Another target? Such centrally driven initiatives risk alienating and turning off the very people vital to their success. Targets are incredibly useful but they also inevitably lead to gaming. Pointing out good practice is wonderful but it isn’t the way innovation spreads. Political leaders in health care so rarely inspire the people who do the real work. This too needs to be understood.
Perhaps the most significant factor that needs facing up to is what really has to change in the NHS for a culture of safety and continuous improvement to thrive. As well as all of us learning the improvement science, we have to engage and retrain every manager and clinical leader who thinks it is more useful to bully and intimidate their staff than use common sense, to be organised and responsive.
We also have to engage and retrain every doctor and nurse and other professional who thinks it is OK to bully, blame and intimidate, or just be plain awkward with anyone – and sometimes everyone – they come across.
While not the norm, I am sure you will all have experiences of coming across such individuals.
We also need to engage and retrain every commissioner, regulator, inspector, executive, manager, non-executive board member and civil servant who think good governance is a polite term for ‘grip’, who think standards are never ambiguous, who think targets and benchmarking are tools with no downside and who think that they could easily do everybody else’s job better than the incumbents can do it themselves.
Now I realise you think I’m exaggerating just for effect – but we have to acknowledge how low morale is and how deep the deep end is in many parts of the NHS. And just how seriously the managers and clinical leaders across the NHS – and particularly across politics, the Department of Health and health care regulation – must live and breathe the Berwick Manifesto for us to start on this journey. This cultural change is the mammoth challenge we face.
I have learned more positive things from Gary Kaplan in the last 10 years than from anyone else I know. But the ‘see-feel’ experience you get – and Mr Hunt has had – in Seattle is just the beginning of a very tricky journey. Success requires us to acknowledge and deal with the numerous barriers and pitfalls along the way.
Let us rejoice that, at last, our political leader sees that there is a worthwhile journey ahead and that Virginia Mason have given us a route map and that absolutely there are ways of making modern health care safe, effective, patient-centred and efficient. So, because of the evidence and not because of the politics, and with our eyes wide open, let’s all just do it.
Stephen is a former NHS medical director and Chief Executive and was a member of the Don Berwick advisory group.