Intended for healthcare professionals

Analysis Personal paper

A transatlantic review of the NHS at 60

BMJ 2008; 337 doi: (Published 17 July 2008) Cite this as: BMJ 2008;337:a838
  1. Donald M Berwick, president
  1. 1Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138, USA
  1. dberwick{at}

    At the NHS Live conference celebrating 60 years of the NHS at the beginning of July, Donald Berwick explained why he admires the UK health system and how it could be even better

    Cynics beware, I am romantic about the National Health Service; I love it. All I need to do to rediscover the romance is to look at health care in my own country.

    The NHS is one of the astounding human endeavours of modern times. Because you use a nation as the scale and taxation as the funding, the NHS is highly political. It is a stage for the polarising debates of modern social theory: debates between market theorists and social planning; enlightenment science and post-modern sceptics of science; utilitarianism and individualism; the premise that we are all responsible for each other and the premise that we are each responsible for ourselves; those for whom government is a source of hope and those for whom government is hopeless. But, even in these debates, you are unified by your nation’s promise to make health care a human right.

    No one in their right mind would expect that to be easy. No wonder that, even at age 60, the NHS seems still immature, adolescent, searching.

    You could have chosen an easier route. My nation did. It’s easier in the United States because we do not promise health care as a human right. In America, people ask, “How can health care be a human right? We can’t afford it.” As a result, almost 50 million Americans, one in seven, do not have health insurance. Here, you make it harder for yourselves, because you don’t make that excuse. You cap your healthcare budget, and you make the political and economic choices you need to make to keep affordability within reach. And, you leave no one out.

    Connection and coordination

    In the US, our care is in fragments. We don’t have a rational structure of inter-related components; we have a collection of pieces. These disconnected pieces cost us dearly. They create what the great health services researchers, Elliott Fisher and Jack Wennberg, call “supply driven care.”1 2 In America, the best predictor of cost is supply; the more we make, the more we use—hospital beds, consultancy services, procedures, diagnostic tests. Fisher and Wennberg find absolutely no relation between supply and use, on the one hand, and quality and outcomes of care, on the other. Here, you choose a harder path. You plan the supply; you aim a bit low; you prefer slightly too little of a technology or a service to too much; then you search for care bottlenecks and try to relieve them.

    In the US, we favour specialty services and hospitals over primary care and community based services. Hospitals are abundant, an invitation to supply driven care. Coordinated care, home health care, hospice services, school based clinics, community social services, and mental health services are poorly defended and insufficient. Public health and prevention are but stepchildren. Here, in the NHS, you have historically put general practice where it belongs: at the forefront.

    In the US, we can hold no one accountable for our problems. Here, in England, accountability for the NHS is ultimately clear: the buck stops in the voting booth. That is why Tony Blair commissioned new investment in the NHS when he became prime minister, why your government repeatedly modifies policies in a search for traction, and why it chartered the report by Lord Darzi.3 This is not mere restlessness; it is accountability at work through the maddening, majestic machinery of politics.

    In the US, we fund health care through hundreds of insurance companies, a zoo of payment streams. Administrative costs approach 20% of our total healthcare bill, at least three times as much as in England. In the US, insurance companies have a strong interest in not selling health insurance to people who are likely to need health care. Many insurance companies try to predict who will need care and find ways to exclude them from coverage. You do not.

    Right choices

    You could have had the American plan. You could have been spending 17% of your gross domestic product and making health care unaffordable as a human right instead of spending 9% and guaranteeing it as a human right. You could have kept your system in fragments and encouraged supply driven demand, instead of making tough choices and planning your supply. You could have made hospitals and specialists, not general practice, your mainstay. You could have obscured accountability, or left it to the invisible hand of the market. You could have a giant insurance industry of claims, rules, and paper pushing instead of using your tax base to provide a single route of finance. You could have protected the wealthy and the well instead of recognising that sick people tend to be poorer and that poor people tend to be sicker, and that any healthcare funding plan that is just must redistribute wealth.

    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, please behold the mess that a less ambitious nation could have chosen.

    Is the NHS perfect? Far from it. The recent magisterial report by Sheila Leatherman and Kim Sutherland sponsored by the Nuffield Trust finds some good news.4 For example, after 10 years of reinvestment and redesign, the NHS has more evidence based care; lower death rates for major disease groups (especially cardiovascular diseases); lower waiting times for hospital, outpatient, and cancer care; more staff and technologies available; in some places better community based mental health care; and falling rates of hospital infection. Other areas show less progress, such as specialty access, cancer outcomes, patient centeredness, and life expectancy and infant mortality for socially deprived populations. The facts are clear and unsurprising: in improving its quality, the NHS is en route, and it has a lot more work ahead.

    A better service

    How can you do even better? I have 10 suggestions:

    Put the patient at the absolute centre of your system of care—In its most authentic form, this rule feels very risky to both professionals and managers, especially at first. It means the active presence of patients, families, and communities in the design, management, assessment, and improvement of care. It means total transparency. It means that patients have their own medical records and that restricted visiting hours are eliminated. It means, “Nothing about me without me.”

    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 drains energy and confidence from the workforce, which learns not to take risks but to hold its breath and wait for the next change. There comes a time, and the time has come, for stability, on the basis of which, paradoxically, productive change becomes easier and faster for the good, smart, committed people of the NHS.

    Strengthen local healthcare systems—What you call “health economies” should become the core of design: the core of leadership, management, interprofessional coordination, and goals for the NHS. I believe that the NHS has gone too far in the past decade toward optimising hospital care—a fragment. Now, it should optimise the processes of care for communities.

    Reinvest in general practice and primary care—These, not hospital care, are the soul of a proper, community oriented, health preserving care system. General practice is the jewel in the crown of the NHS. Save it. Build it.

    Please don’t put your faith in market forces—It’s a popular idea: that Adam Smith’s invisible hand would do a better job of designing care than leaders with plans can. I find little evidence that market forces relying on consumers’ choosing among an array of products, with competitors’ fighting it out, leads to the healthcare system you want and need. In the US, competition is a major reason for our duplicative, supply driven, fragmented care system.

    Avoid supply driven care like the plague—Unfettered growth and pursuit of institutional self interest have been the engines of low value for the US healthcare system. Oversupply has made care unaffordable and hasn’t helped patients at all.

    Develop an integrated approach to the assessment, assurance, and improvement of quality—England now has many governmental and quasi-governmental organisations concerned with doing just that, but they do not work well with each other. The nation needs a clear, agreed map of roles and responsibilities that amount, in aggregate, to a coherent system for aim setting, oversight, and assistance.

    Heal the divide among the professions, managers, and government—Since at least the mid-1980s, a rift has developed between the formally organised medical professions and the reform projects of government and the executive. The NHS and the people it serves can ill afford another decade of misunderstanding and suspicion between the professions, on the one hand, and the managers, on the other. It is the duty of both to set it aside.

    Train your healthcare workforce for the future, not the past— That workforce needs to master a whole new set of skills relevant to the improvement of health care as a system: patient safety, continual improvement, teamwork, measurement, and patient centred care, to name a few.

    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 really did mean to create an enterprise whose product—whose purpose—was not care, but health. Maybe they knew then, as we surely know now, that great health care, technically delimited, cannot alone produce great health. The high profile epidemics of severe acute respiratory syndrome (SARS), bovine spongiform encephalopathy, and avian influenza cannot hold a candle to the damage of the durable ones of obesity, violence, depression, substance misuse, and physical inactivity. Would it not be thrilling in the next decade for the NHS to fully live up to its middle name?

    The only sentiment I feel for the NHS that exceeds my admiration is my hope. I hope you will never, ever give up on what you have begun. I hope you realise and reaffirm how badly you need—how badly the world needs—an example at scale of a health system that is universal, accessible, excellent, and free at the point of care—a health system that, at its core, is like the world we wish we had: generous, hopeful, confident, joyous, and just. Happy birthday.


    Cite this as: BMJ 2008;337:a838


    • Analysis, doi: 10.1136/bmj.a824
    • Contributors and sources: This article is based on a speech given at the NHS Live conference at Wembley stadium on 1 July 2008.

    • Competing interests: None declared.

    • Provenance and peer review: Commissioned based on the author’s suggestion; not peer reviewed.