Dr Donald Berwick called in to head up review into NHS safety
Following on from the Francis Enquiry
and the "truly dreadful events" at Mid Staffordshire Hospitals, David Cameron appointed Dr Donald Berwick (a paediatrician who is internationally known for his work on safety as director and co-founder of the Institute for Healthcare Improvement in Boston), to head a 3 month review into NHS safety
and "to make zero harm a reality in our NHS".
Introducing Prof Berwick yesterday, ahead of a major public conference, Jeremy Hunt, the Health Secretary, said he had "paid the political price in his own country for his friendship and support of the NHS. He knows that our NHS is not the caricature of socialised medicine
that it is often described as in the United States, but actually something quite different - the vision that no matter what your background you should be able to get the very highest standard of care
Mr Hunt went on to say that the "zero harm approach will not eliminate harm completely, but should make it exceptional."
Dr Berwick addressed the 3 fundamental problems identified
by the Francis report, namely that managers were ignoring high death rates
, patient safety and inconvenient facts, in order to hit targets. He said: "This is the normalisation of deviance - the alarms were ringing but they went unanswered."
He went on to warn that the failings in Stafford occurred because hospital staff became blind to what was going on around them
, and that they had assumed that the standards which were being tolerated were normal
. As such, the NHS was now "facing a crisis", and would "descend into chaos" if the right course was not taken.
Prof Berwick said NHS staff should not distance themselves from what happened in Stafford and that they should not feel reassured that the same thing could not happen again because "without constancy there will be no improvement
He stressed the need for transparency
within the NHS, saying that: "Only by turning the lights on what we do, can we ever learn what the next thing to do is. Transparency is key to improving."
Significantly, Dr Berwick said that the NHS must remember that "we are guests in our patient's lives, not hosts in our organisations".
He said all hospitals now needed to improve, to avoid future tragedy
. "Systems decay" said Prof Berwick. "They are never ever on automatic. You only have 2 choices when it comes to quality of care - to go forward or back. There is no standing still, you will descend into chaos."