Preventing small problems from becoming big problems in health and care

I recently attended the 26th conference of the US Institute of Health Improvement, and had the privilege of hearing Don Berwick and Atul Gawande amongst many others sharing their reflections on the changing landscape of health and care. I was struck by the strong focus on looking for new ways to reduce staff burnout and to invest more in the human aspects of care. Having strong and resilient relationships at work was seen as key to providing sustainable care. Kindness and compassion were just as important to good care as technical skills and knowledge. Addressing these aspects of care, both for service users, patients and for professionals, was given great emphasis. Gerald Hickson spoke about the "power of an honest conversation" as an important part of this process.

Our work on professionalism reflects this pursuit of greater awareness and understanding of the interpersonal aspects of care. I am very pleased that our latest research in this area continues this exploration, and reflects the mood and direction of thinking in a wider arena. Preventing small problems becoming big problems in health and care explores the reasons behind incremental disengagement, where challenging circumstances appear to lead to concerns about practise, and eventually to a complaint. Patients and service users in the study recognised the pressures and challenges of delivering high quality care, and the need to ensure professionals were supported to do their jobs well.  They said they wanted to be seen by professionals who were compassionate, communicative, and consistent in the care they provided.

Feedback from professionals in the study highlight the links between poor supervisory structures, lack of peer support, professional isolation and disengagement from practise. Disengagement was characterised as a symptom of underlying, often longstanding issues in the workplace which could be addressed and might be resolved before complaints arose. Not rocket science to anyone working in health and care services, but nevertheless important to the debate about what needs to change.

I was struck by words from Atul Gawande who spoke about ways in which services and professionals must evolve in response to the changing needs and expectations of society. A strong advocate for team based care, and the need to break down hierarchies amongst professionals.

Gawande suggested that "The relationship between clinicians and institutions has been like a tenant and landlord relationship. Clinicians expected to be left alone by their landlords to do what they did. But now, it has changed. Thinking about what happens in hospitals and clinics, and allowing others in, has become crucial."

This notion of "allowing others in" is enormously complex. At one end of the spectrum, this means allowing reflection and self awareness to generate those honest conversations with trusted colleagues at an early stage, as a means of addressing problems early on. At the other end of the spectrum, it can mean investigation by a regulator. Between the two ends lie conversations and interventions by managers, educators, and professional associations. My hope is that our work with Zubin Austin, Carole Chistensen-Moore and Joan Walsh will help to generate more activities at the reflective end of the spectrum, and reduce the activities at the regulatory end. It is in everyone's interest to prevent harm, to reduce complaints, and to see more emphasis on support, kindness and compassion in health and care.

Anna van der Gaag

Don Berwick: a challenging voice from the US

The government has published its initial response to the Francis Report, with a wide range of proposals to take the recommendations forward (1).  

Amongst the many initiatives, Professor Don Berwick, a veteran of the healthcare quality movement in the US and former adviser to President Obama, has been invited to report on ‘a whole system approach to make zero harm a reality in the NHS’ (1).  

For over twenty years, Berwick has been a leader in the field of health improvement, looking at how services can improve to make care better, safer and more efficient. His work at the Institute of Health Improvement has made a major contribution to understanding quality and safety in health care.

At a recent lecture at the Kings Fund in London (2), Berwick suggested that the UK health and social care system, like the US system, needed radical solutions if we are to achieve ‘better care, better health and lower cost’. Besides the economic pressures, which are considerable, he talked about the public and the professions being ‘confused’ about what the future of health care delivery would look like. Patients and their carers worry that changes will mean a loss of services, and the professions are unsure about what kind of practice they will have in the future. At a political level, in the US at least, Berwick spoke of a loss of authentic dialogue about exactly what changes will deliver better outcomes.

A quietly spoken man with a powerful combination of conviction and experience, Berwick’s vision had a moral dimension – with a challenge to professionals to focus on the needs of the vulnerable in society. He suggested that, in the future, care must be less centred on hospitals, and be much more community based. He saw the future of care delivered in teams made up of individuals with ‘an expanding scope of practice’, able to meet the needs of local populations, using new technologies and advocating a new approach to involving service users in the decisions about their own care.

Berwick illustratated his vision with examples of innovative care in the US,  many of these based on integrated teams, with little or no heirarchy, and much less doctor-focused than our current systems advocate. He said the first rule of change is to cooperate. The training of health care professionals  must include ‘process improvement, courage, transparency and openess and above all cooperation’.

These are huge ideas, and huge challenges, but arguably they articulate what many people in the UK already recognise.  When HCPC was established over 12 years ago, there was resistance to the idea of an integrated system of professional regulation – where all professions were subject to the same regulatory processes, one register, one fitness to practise process, shared standards and one Board with oversight of all.

Today, the HCPC is seen as an effective and efficient regulator of 16 health, psychological and social work professions. It may well be a model for the future which Berwick describes.

 

Anna van der Gaag

Chair

HCPC

Notes

1)    Department of Health (2013) Patients first and foremost: the intial government response to the Report of the mid Staffordshire NHS Foundation Trust Public Inquiry

2)    Don Berwick (2013) The role of clinical leaders. Kings Fund lecture, 16 April 2013. www.kingsfund.org.uk