CEO Diary W/C 5th August 2013

MONDAY-WEDNESDAY

This is not a job you switch off from. This can make it sound like a burden, but it's more that the complexity, challenge, and potential to make a difference is a constant stimulus. I spent 12 years in health management consultancy, and I would struggle to identify examples of real social value in my work. This feels like it matters.

This preamble is to justify (and hopefully normalise!) how pleased I was to be on leave and be able to read the Berwick report in full and at leisure, and watch the response to it through Twitter and email alerts. The report received quite a polarised response - outside of the official 'we welcome this report' messages. I understand that there is a degree of report fatigue, and a cynicism borne of experience that says 'we've heard this talk before, where's the action?' but I would say that Don Berwick has produced a report of clarity, importance, and huge value. 

Some commentators have criticised the report; that it is long on narrative and short on decisive action, that it contains nothing we did not already know. I think this misunderstands what the report is trying to do. This report is a mirror that shows us as we are, and does so in a clear and persuasive voice that can be heard in the heart of government. It is for every NHS leader to read, understand, reflect, and act - if these problems and solutions are already known and understood, why haven't we acted? We cannot sit back and wait for someone to fix it for us.

There's a great deal of substance in its 46 pages, but these are the key points I take from it as a commissioner:

1. Problems with patient safety are endemic to the NHS and all health systems. Behaving as though Mid-Staffs is an anomaly is self-delusion; It is at the extreme end of a continuum of avoidable harm. We must ALL do better, and better means the continual reduction in avoidable harm in every local system.

2. The supremacy of performance and financial targets - and the culture of blame and fear used sometimes to ensure their delivery - is deeply corrosive. Staff want to care and be proud to do it well. Leaders must refocus the agenda back to patient safety, and create the environment, support and training, to foster success.

The two sentences in the report that really struck home are: 

'If the system is unable to be better, the aim becomes above all to look better, even when truth is the casualty.'


[solution: absolute transparency, and the involvement of patients, carers, community leaders at every level of the local NHS system]

'Responsibility is diffused and not clearly owned. When so many are in charge, no one is.'

[solution: while we wait for central government to consider any future rationalisation of commissioners and regulators, locally we can coordinate our patient safety work - sharing information and acting collectively to improve patient safety]

The CCG has always identified quality and safety as its top priority, and regularly reviews and debates these issues, but we can do much more. My Quality Director and I will be taking a summary of Berwick and some specific recommendations to the Governing Body:

1. A CCG safety strategy, that systematically identifies key areas of avoidable harm, sets clear goals for harm reduction, and works to support providers to succeed in harm reduction.

2. Greater involvement of patients and carers in our quality and safety improvement and assurance systems.

3. Training available for all on the modern tools for safety assessment and improvement - our staff, Governing Body, members of visit teams, our member practices

4. Further investment in the promotion and operation of our feedback and complaints systems - Patient Opinion, SickAdvisor, NHS Complaints, Public Meetings.

5. Refocus the patient stories at the beginning of each GB meeting on key areas of avoidable harm, and use them to question the performance of the Norwich system.

These measures - in addition to the systems already in place - will have a significant impact, and are not dependent on national action or changes in policy. Every right thinking leader will have looked at the horrors of Mid Staffs and said something like  'not on my patch, and not on my watch.' Berwick tells us how.

THURSDAY

It was timely that my first day back was at the Quality Surveillance Group - a monthly meeting chaired by the NHSE Area Team, and attended by all those organisations that make up our 'diffuse' system of responsibility: NHSE, CCGs, CQC, Monitor, TDA, Healthwatch, and the local Deanery. We share information about the healthcare providers in our system, identify concerns, and where appropriate conduct greater levels of surveillance, or in more serious cases recommend to the Region that a Risk Summit be initiated. The group has the potential to be an effective local solution to the diffuse regulatory and assurance system, and there is much to commend about the way in which information is shared and analysed.

However, I have asked for the Berwick report to be reviewed at the next meeting because there are things it must do better:

1. The meeting is confidential and FOI exempt. I was never comfortable with this (we promote complete openness from our providers but then have confidential meetings where we talk about them and where they have no voice) but in the light of the Berwick recommendations it seems indefensible. Every document and comment shared in our quality surveillance process should be shared with providers and subject to public scrutiny.

2. The attendees need to be trained in safety assurance and improvement - many of us (me included) are well intentioned amateurs, bringing information, experience, and I hope common sense to the discussions, but we do not yet have the expertise to ensure our actions are fully effective.

3. We need to have more tools beyond the current two (enhanced surveillance, and recommend a Risk Summit), which can feel so limited that we are at times doing little more than hand-wringing. There is further local action we can take to support commissioners and providers

Berwick asks us to rank the elements of quality as defined by the NHS. Patient experience and effectiveness of care are important, but patient safety - avoiding harm from the care that is intended to help - must be the No.1 NHS priority. This I can understand, explain, support, and demand. The Francis report was a long sobering read, the Keogh review a pragmatic and excellent process, but Don Berwick has given me a 'light-bulb' moment of clarity about the fundamental purpose of NHS leadership.