The Berwick report on patient safety (“A promise to learn; a commitment to act: improving the safety of patient in England”) has spirited defenders and also spirited critics. In its favour, it is much shorter and much easier to read than the Francis Inquiry report (mercifully). But after a couple of read-throughs and some serious pondering, I am putting myself in the latter camp of critics, despite finding much to strongly agree with in the review. Ultimately it misses the mark because there is no force behind its admonitions. Does that mean those of us who are disappointed in the lack of teeth in the Berwick review are missing the point? I think not.
Aiming for the bullseye
We had high hopes for a bullseye on engagement and leadership, and not just in relation to patient safety, but Berwick missed it. Notwithstanding the issues around regulation and mandatory staffing levels which Berwick ducked according to some, there are other things that should have been there that are simply absent. That undermines the rationale for the review in the first place.
A more cynical commentator might conclude that it was all meant to be a delaying exercise in order to let the Francis Inquiry findings start to fade from Ministers’ and media minds and get us into the “great forgetting” that is the summer holiday break. Whether any of this will get resurrected in the frenzy of the party conference season in the autumn will be interesting to see.
What Berwick missed
So what are the areas we think Berwick missed the bullseye on? Basically there are three:
1. Leadership. Berwick is, rightly, keen on it and goodness knows it has been in short supply in the NHS. But leadership is never going to deliver the changes required as long as patients, carers and active citizens are not equal in the leadership stakes with clinicians and managers. The review ignores this and keeps patients and carers in particular on the outside looking in and with no developmental support. A fatal flaw.
2. Patient and public involvement. PPI is warmly regarded in the report, but there is nothing new in it and, most tellingly, no recommendations for the NHS to actually do anything to implement the warm words. Same old, same old isn’t going to deliver the “patients as assets” changes that we much have in order to recreate the NHS in England for the 21st century. Maybe the forthcoming guidance on the duty of participation will be better, let us hope so anyway.
3. Enforcement. This is downplayed in favour of “learning ” as the main agent of culture change. This may be noble, but in the face of the overweening NHS culture and averseness to risk it is simply naive. Change of the sort that’s needed isn’t going to happen in a cold (and worsening) financial climate. It isn’t either/or. Enforcement and learning must happen together for synergy. The NHS and all public services must learn some very tough lessons and learn them quickly.
Vital ingredient missing from the velvet glove
Promises to learn and commitments to act all sound wonderful. But we cannot leave things like patient leadership and engagement of patients, carers and citizens to “learning” alone. It’s too slow, too patchy and, above all, too risky.
Velvet gloves are all very nice, but there has to be some steel inside them somewhere. We are sorry that Prof Berwick and his team left out that vital ingredient.