Five minutes with . . . Don Berwick

BMJ 2016; 355 doi: (Published 26 October 2016) Cite this as: BMJ 2016;355:i5742
  1. Gareth Iacobucci
  1. The BMJ

A paediatrician by background, Berwick is the founder and chief executive officer of the US Institute for Healthcare Improvement and an adviser to NHS England’s vanguard programme, which is testing new models of healthcare delivery

“The vanguards have been at it for about two years. The triple aim is better care for people, better health for populations, and lower per capita cost.

“They’re doing pretty well. By working on team based care, coordinating care, anticipating need instead of being reactive, by empowering clinicians, by giving patients more voice in their own care, [some vanguards] are achieving double digit reductions in emergency department use, and double digit reductions in unscheduled hospital use.

“In one area, they achieved serious reductions in elective consultations because patients were headed for interventions they actually didn’t need, and in another they’re talking about reducing demands for GP care by 30-40%. This is not rationing; it’s not taking away things people need. It’s discovering that you have different ways to meet needs.

“There are also six care home vanguards that have developed a comprehensive model of avoiding unnecessary admissions to hospital. The basic framework is a strong evidence based assessment process to know the level of risk, multidisciplinary teamwork, and focusing hard on nutrition and physical activity so that people are given support to remain active. These are all scientifically grounded evidence based interventions. But you really need to think systemically and be able to build processes to support it.

“I’m impressed by some of the vanguards that are moving services from the hospital to primary care. In some places there are very strong primary care organisations and there’s no serious problem gaining the interest of the GPs. In others there is a much stronger history of small practice, and it’s about winning them over.

“The biggest barrier is that GPs are working extremely hard and don’t have the time to inquire and learn. This is a leadership issue. Whoever is responsible, whether it’s a commissioner or STP [sustainability and transformation plans], are they going to regard learning as productivity or not? If a GP needs five hours to master this, that’s got to be defined.

“In vanguards it’s about getting results. The question is will there be time for them to succeed? It’s not going to be this year that the harvest comes. I would keep the heat on—it’s important for people to feel urgency. But it’s important for the government and executive leadership to respect the learning processes that are under way.”

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