Health staff know where savings can be made, says US “zero harm” expert

BMJ 2013; 346 doi: (Published 18 April 2013) Cite this as: BMJ 2013;346:f2506
  1. Zosia Kmietowicz
  1. 1BMJ

Plenty of opportunities exist to cut UK healthcare costs without reducing the quality of care, or even improving it, but health service leaders need to embrace change to deliver them, a leading authority on delivering better healthcare has said.

Donald Berwick, a paediatrician who cofounded and led the US Institute for Healthcare Improvement for 18 years, said that waste in the US healthcare system had been estimated at between 21% and 47% of expenditure. With annual healthcare costs in the United States in the region of $2.7 trillion (£1.8 trillion; €2.1 trillion), better management could result in savings of up to $1.2 trillion, with the median calculated at 34% of the total, or $910bn, said Berwick.

Although the figures derived from the US healthcare system, Berwick was confident that similar savings could be found in the UK health services. Categories of waste included overtreatment (maximum wastage in the US estimated to be $226bn), failures of care coordination ($45bn), failures in the execution of care delivery ($154bn), administration complexities ($389bn), pricing failures ($178bn), and fraud and abuse ($272bn), he said.

Healthcare workforces know about the waste in their systems, said Berwick at a lecture on clinical leadership of healthcare reform at the health think tank the King’s Fund on 16 April. “And they know how to find savings if you set them loose,” he added.

“The opportunity is there for the people who give care to change care,” Berwick told the audience, and he listed doctors, nurses, pharmacists, and executives as purveyors of potential change.

But he emphasised that change needed to happen “at scale,” because “there is not time to do less.” This meant that staff members needed to take their ideas to the boards of hospitals or other providers of care.

Population based funding of healthcare provided the freedom to innovate, whereas systems where providers were paid for the episodes of care they provided worked against change, he said.

“In the UK, hospitals are incentivised to stay busy, and there is continual restructure of the health service. That isn’t going to work,” said Berwick.

But there was the potential in the UK for cities or other local healthcare economies to deliver what Berwick described as the “triple aim” of “better care, better health, and lower costs.”

He said, “Every system is designed to get the results it gets, therefore it is necessary to change the system. Changing the system is the route to improvement.”

Berwick gave a number of examples of where the “triple aim” was being achieved. The Nuka model of care run by the Southcentral Foundation in Alaska was set up in 2002-3 to provide primary healthcare services for 55 000 people. Its community based, team approach had halved the use of emergency and urgent care services, reduced specialty visits by 63%, reduced hospital admissions by 53%, and reduced primary care visits by 36%.

Another scheme in Alaska, the AFHCAN telemedicine “cart” comprising eight medical instruments and a camera, had reduced by 70% the need for doctors to travel to remote Alaskan communities.

Berwick also pointed to the Whole System Demonstrator study, which compared telehealth at home and usual care of patients with diabetes, chronic obstructive pulmonary disease, or heart failure in 179 general practices in England. The study found that telehealth reduced mortality and numbers of emergency admissions.1

Berwick referred to the ideas of the Harvard cardiologist Bernard Lown, who recently suggested that half of all revascularisation procedures in the US for stable angina were unnecessary and that conventional medical care was just as good. “What if he is right?” asked Berwick. Such examples showed that innovation was possible. “We must do it, and we can do it,” he concluded.

The prime minister, David Cameron, has appointed Berwick to advise on improving safety in the NHS in England in the wake of the report by Robert Francis QC into the Mid Staffordshire NHS Foundation Trust.2 Berwick’s report is expected in July.


Cite this as: BMJ 2013;346:f2506