The Wardman Wire

This is Simon Sarmiento’s fifth and final Guest Column on the Wardman Wire, while David Keen is on holiday from the blog. This week Simon examines a critical appreciation of the National Health Service.

This is my last guest column for the month of August. I want first to draw attention to a recent critique of the National Health Service, which a member of my family who works in the NHS pointed me to recently.

The author is a distinguished American health expert, Professor Donald M. Berwick of Harvard. He’s a pediatrician but also Professor of Health Policy and Management at the Harvard School of Public Health. And he is also President and CEO of a not-for-profit organization called the Institute for Healthcare Improvement. It was in this capacity that he spoke in July to a big gathering of NHS staff at Wembley called NHS Live. You can watch his speech, as actually delivered. You can read what looks like the prepared text here, and an edited version was published in the British Medical Journal.

He had some very positive things to say about our Health Service, and he also had some very sound advice for its improvement. We in Britain tend to complain a lot about NHS shortcomings; this should give us a better perspective on how fortunate we are.

NHS: an astounding human endeavour

Let me first quote him so that you are in no doubt about his basic opinion:

I am romantic about the NHS; I love it. All I need to do to rediscover the romance is to look at health care in my own country.

And he goes on:

The National Health Service is one of the truly astounding human endeavors of modern times. Just look at what you are trying to be: comprehensive, equitable, available to all, free at the point of care, and - more and more - aiming for excellence by world-class standards.

…Britain, you chose well. As troubled as you may believe the NHS to be, as uncertain its future, as controversial its plans, as negative its press, as contentious its politics, as beleaguered as it sometimes feels, please lift your eyes and behold the mess - the far bigger, costlier, unfair mess - that a less ambitious nation could have chosen.

Far From Perfect

But he also has some very profound recommendations for how to make the NHS even better than it is. Some of these may sound very basic, obvious even, but speaking as an ordinary consumer of the NHS, with no special knowledge, and no particular axe to grind, I think they are spot on. Here’s my précis of them, but read the whole thing for yourself. And while you are reading, think about how these recommendations (with minor terminology changes) might easily apply to other organisations, even dare I say it, to the Church of England.

1. First, put the patient at the center - at the absolute center of your system of care. Put the patient at the center for everything that you do. In its most helpful and authentic form, this rule is bold; it is subversive. It feels very risky to both professionals and managers, especially at first. …It means that we who offer health care stop acting like hosts to patients and families, and start acting like guests in their lives.

2. Second, stop restructuring. In good faith and with sound logic, the leaders of the NHS and government have sorted and resorted local, regional, and national structures into a continual parade of new aggregates and agencies. Each change made sense, but the parade doesn’t make sense. It is, I think, time to stop.

3. Third, strengthen the local health care systems - community care systems - as a whole. I believe that the NHS has gone too far in the past decade toward optimizing hospital care - a fragment - and has not yet optimized the processes of care for communities.

4. Fourth, to help do that, reinvest in general practice and primary care. General practice, not the hospital, is the jewel in the crown of the NHS. It always has been. Save it. Build it.

5. Fifth, please don’t put your faith in market forces. In the US, competition has become toxic; it is a major reason for our duplicative, supply-driven, fragmented care system. Trust transparency; trust the wisdom of the informed public; but, do not trust market forces to give you the system you need

6. Sixth, avoid supply-driven care like the plague. Unfettered growth and pursuit of institutional self-interest has been the engine of low value for the US health care system. It has made it unaffordable, and hasn’t helped patients at all.

7. Seventh, develop an integrated approach to the assessment, assurance, and improvement of quality. England now has many governmental and quasi-governmental organizations concerned with assessing, assuring, and improving the performance of the NHS. But they do not work well with each other. …it is one violation of my proposed rule against restructuring that I have no trouble endorsing.

8. Eighth, heal the divide among the professions, the managers, and the government. Since at least the mid-1980’s, a rift developed that has not yet healed between the professions of medicine formally organized and the reform projects of government and the executive.

9. Ninth, train your health care workforce for the future, not the past.

10. Tenth, and finally, aim for health. I suppose your forebears could have called it the NHCS, the “National Health Care Service,” but they didn’t. They called it the “National Health Service.” Maybe they meant it.

Veils in Southampton

Now, the second thing I want to draw attention to is the column on Comment is Free that Riazat Butt wrote this week. Last weekend, she went shopping in Southampton with her sister, and had an unpleasant experience in Primark. So she wrote it up:

My sister has worn a face veil for six years. She lives in Birmingham, where it is common to see women shrouded in black, however the sight is more unusual in Southampton, where my parents live and where, at the weekend, my sister was called “a ninja woman”.

And her concluding question provoked an avalanche of responses online:

My sister wears a face veil because it is something she wants to do. She knows not all Muslim women feel the same and she is not on a mission to force others to adopt the same dress code as her. She is not breaking the law. She is, as she sees it, minding her own business, being a mother and bringing up her children. My question is: the next time someone calls her a name, how should she respond?

It seems clear from these reactions that Riazat has raised an issue on which many Guardian readers don’t feel quite as liberal as you might expect them to be. The same issue came up this week in Venice, of all places, where the authorities took a sensible stand.

Wrapping Up

In conclusion, thanks to Matt (and Dave) for giving me this opportunity to ramble during August about whatever took my fancy. You can wake up now. Dave will be back next week.