The Real Don Berwick

Published September 18, 2013

Consider this –

…[F]or many patients the most basic elements of care were neglected. Calls for help to use the bathroom were ignored and patients were left lying in soiled sheeting and sitting on commodes for hours, often feeling ashamed and afraid. Patients were left unwashed, at times for up to a month. Food and drinks were left out of the reach of patients and many were forced to rely on family members for help with feeding. Staff failed to make basic observations and pain relief was provided late or in some cases not at all. Patients were too often discharged before it was appropriate, only to have to be re-admitted shortly afterwards. The standards of hygiene were at times awful, with families forced to remove used bandages and dressings from public areas and clean toilets themselves for fear of catching infections.

These conditions caused the deaths of an unknown number of patients. It may sound like a Nazi concentration camp or a third-world “failed state” like Yemen, but it wasn’t. It took place in one of the most advanced industrial democracies in the world.

What should happen in such a situation? Should the facility be closed? The staff fired? Management arrested and tried for manslaughter? At least sued for malpractice? Would it make any difference to you if it was a private or a public facility?


In fact the quote above was taken from a press release announcing the “Final Report Of The Independent Inquiry Into Care Provided By Mid Staffordshire (England) NHS Foundation Trust.” The 500-page report was mandated by the House of Commons and chaired by Robert Francis QC, who was quoted as saying –

It is now clear that some staff did express concern about the standard of care being provided to patients. The tragedy was that they were ignored and worse still others were discouraged from speaking out.

Management knew what was happening, but failed to correct it and even suppressed any discussion of the problems.

Again, what should be done?

Enter Don Berwick.

Dr. Berwick was brought in to chair another committee — the National Advisory Group on the Safety of Patients in England, which issued another report and recommendations for action.

Berwick’s report is a complete whitewash of the situation. Here are a few of their observations and my comments.

Let’s start with Berwick’s personal letter to “Senior Government Officials and Senior Executives of the Health Service.” He writes

You are stewards of a globally important treasure: the NHS. In its form and mission, guided by the unwavering charter of universal care, accessible to all, and free at the point of service, the NHS is a unique example for all to learn from and emulate.

Good grief, could he be more gushing, even in the face of glaring and criminal incompetence? No one on earth wants to emulate the NHS. Not one nation is trying to replicate the British system. It is the laughing stock of the world. The things about it that Berwick admires are the very things that made this atrocity inevitable as we will discuss below.

Patient safety problems exist throughout the NHS as with every other health care system in the world.

So, it’s no big deal, just the way things go. Get used to it.

NHS staff are not to blame — in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.

NHS staff are not to blame? Who developed the procedures, conditions, environment and constraints? Where is the procedural rule that told the staff to let people lie in their own feces and urine? Who decided to leave food and water out of the reach of the patients? What kind of monster would step over a suffering patient and do nothing? Would Don Berwick be so sanguine if these things happened in a private hospital? Of course not! Heads would roll. But since it is a government hospital, no one is to blame.

In some instances, including Mid Staffordshire, clear warning signals abounded and were not heeded, especially the voices of patients and carers (sic).

So people ignored the abundant “warning signals” and those people are also “not to blame”?

The system must…abandon blame as a tool and trust the goodwill and good intentions of the staff.

What goodwill? What good intentions? If Ford built defective cars that killed hundreds of innocent people, would Don Berwick insist that we “trust the goodwill and good intentions of the staff?”

Many people probably died from avoidable causes, and many more suffered unnecessary indignities and harm…(but) without ever forgetting what has happened, the point now is to move on.

Yes, move on. Nothing to see here. No one is to blame. No one is accountable. “Many people probably died from avoidable causes” and that is really sad, but let’s “move on” to happier topics.

Some of the recommendations are contradictory. Berwick’s commission says that everyone involved in the system must be committed to constant improvement and patient safety, but it also says –

(The NHS should) ensure that responsibility for functions related to safety and improvement are vested clearly and simply in a thoroughly comprehensible set of agencies, among whom full cooperation is, without exception, expected and achieved.

So, on one hand everyone must be involved, but on the other, it is the responsibility of a limited number of agencies, allowing everyone else to say, “Sorry, that’s not my job, it is the work of the Bureau of Patient Safety.”

Most of the report is a long series of self-serving platitudes about continual improvement, life-long education, focus on the patient, and so on. It insists that patients are central to the mission, but even this is contradicted by the make-up of the commission itself. The appendix notes that –

The Committee assembled was dominated in a majority by scientists — experts in organizational theory, quality improvement, safety and systems — and with a healthy minority of people currently in management positions within the NHS in England.

Where are the patients who are supposedly so central to the whole shebang? Not worth including, I guess.

And here is the real problem with the NHS. Like the commission itself, patients are an afterthought. They have no power, no authority in the NHS.  The entire system is based upon the idea that well-meaning experts will do things for (or to) supplicating patients who get their services for free and have no choice in what they get.

But the current scandal shows that these experts are not always well-meaning or even competent. What happens to the hapless patient then? They are left to lie in their urine-soaked beds with food and water out of reach. There is no recourse, other than to “move on.”

Without patient empowerment, there is no “system” that can prevent such abuses. We can implore the experts to be caring and competent all we want, but some will not be and it is impossible for committees to police every action by every “caregiver.” And if no one is ever “blamed” for any wrong doing, it is futile to even try.

Another excuse provided by Berwick’s committee was recent budget cuts and resulting staffing shortages. Faced with such shortages, what is a hospital to do? Well, it might have requested that patients make up the difference. It might have charged patients a small portion of the costs, maybe $10 a day, $25 a day, whatever it takes to avoid the staffing shortages. I expect patients would have gladly paid such a fee to avoid the humiliation, pain and even death they experienced by getting their care for “free.”

But such a remedy would have violated Dr. Berwick’s devotion to the NHS’s “unwavering charter of universal care, accessible to all, and free at the point of service.” So, political ideology trumps all else. Sure, patients may suffer, but they suffer for free and we experts can pat ourselves on the back for being so caring.