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The Berwick Review: We Are All Bed Managers Now

August 11, 2013

So, the Berwick Review has recommended that the NHS  ‘Place[s] the quality of patient care, especially patient safety, above all other aims’ (Executive Summary, p.4). You what? Are we seriously saying that the government spent thousands of pounds commissioning an ‘international health care safety expert’ to complete ‘a broad review of all 290 of the Francis Report’s recommendations’ and distil his thoughts into a written report on how ‘the health service can can improve its whole-systems approach to safety’, just so he could tell them that the NHS should ‘place the quality of patient care, especially patient safety, above all other aims’? They should have got me to do it! I could have told them exactly the same thing and I would have been happy to receive a fraction of what Berwick’s team probably charged!
To be fair to Professor Berwick, there is a context to all this. His review was part of the government’s response to the Francis Report and the main reason for his insistence on the primacy of patient safety is to provide a contrast to and a warning against the ‘incorrect priorities’ – hitting targets and reducing costs – that held sway at Mid-Staffordshire. The trouble is that while it’s obviously impossible to argue against patient safety in the abstract, the reality for health workers is that ‘safety’ is not a monolith; it is, instead, the subject of hour-by-hour or even minute-by-minute negotiation between competing definitions held by different groups of staff and by patients themselves. Nurses, whose role situates them at the nexus of management demand and patient need, may become stressed if they are expected to simultaneously uphold diametrically opposed ideas of what is important.
This clash of priorities is often at its starkest over the issue of patient throughput. From a management perspective, patient safety is identified with avoiding the risk of the financial penalties which may be incurred by Trusts if more than 5% of ED patients wait over four hours for admission, discharge or transfer.  Money paid out in financial penalties ultimately reduces the pot available for overall care, so delays could be seen (in the broadest sense of the term) as a safety issue. There is a secondary emphasis on assessment and documentation, born out of a defensive fear of costly litigation.
Ward nurses tend to concentrate much more specifically on the individuals who are actually in front of them. Their priorities are meeting patients’ needs for care, protecting them from injury and ensuring that they receive prescribed medication on time and at the correct dosage. Tensions arise when nurses are dragged away from these activities to respond to barked commands of  “I need to speak to nurse in charge immediately” from managers on the phone from ED or elsewhere. When this happens, nurses are, in effect, being instructed to de-prioritise the professional imperative of direct patient care and instead adopt the management priority of efficient bed management.
For hospital nurses, the effect of the targets culture may not have been intented, but it has been profound. For them, bedside nursing has become a casualty of the scramble for patient turnover and the avalanche of assessments. More and more, nursing has been forced to foresake its own agenda of patient safety in favour of the management-defined agenda of patient safety. There is a sense in which we are all bed managers now.
Professor Berwick’s solution to this problem is to ‘introduc[e] new models of care and new partnerships among clinicians, patients and carers that can produce better care at lower cost’ (p.14). Well Sir, that’s a fine aspiration – but unfortunately it completely misses the point that a ‘new model of care’ has indeed been introduced into the NHS very recently. It’s called Clinical Commissioning and – however much the good Professor might wring his hands about’ incorrect priorities’ – it embeds more deeply than ever the culture of target-hitting and data-gathering. Even if financial penalties for missing targets were abolished tomorrow (not on the table, but humour me if you will), Trusts would still have to compete for contracts from Clinical Commissioning Groups, and they can only do this by backing up their bids with favourable performance indicators.
This is not to say that a market model of health is necessarily inimical to compassionate care. It doesn’t have to be. But in the current environment of financial cutbacks, traditional nursing values are at increased risk of being squeezed out by the more aggressive and articulate business paradigm.  The recent media alarm about uncaring nurses (exaggerated no doubt, but still presumably with a grain of truth to it) provides some evidence that this is already happening.
The Berwick Review suggests that ‘the government, commissioners and health care providers should strive to strike a balance between minimising risk and allocating resources’ (p.14), but gives no clue as to how it can be achieved. In a characteristically blunt blog post, the great Roy Lilley likens this to ‘teenage girls dancing around their handbags at a youth club disco [who] don’t have the confidence to Tango and tangle with real issues, Rhumba and rumble with the vested interests to really change the NHS’. Nurses, meanwhile, are left to decide for themselves where to draw the line between the competing claims of management and nursing. The pressure they are under to jump a certain way was eloquently summed up in a canteen conversation I overheard not long ago:
Final Year Student (evidently preparing for job interview): So…what sort of things do they ask you?
Staff Nurse 1: Well, they look for you to mention certain key words, like accountability, dignity, compassion, lifelong learning, the Code of Conduct…
Staff Nurse 2: Yeah, but when you get the job though, all that goes out the window. It’s just beds…(laughter all round).

The Berwick Review – otherwise known as A Promise to Learn – A Commitment to Act; Improving the Safety of Patients in England by the National Advisory Group on the Safety of Patients in England is available to download here:

The link to Roy Lilley’s blog post on the same subject doesn’t seem to work. You can access it from my Twitter feed – the retweet of June Girvan’s 7th August tweet should work.

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