Roger Jones is right to highlight Berwick’s relevance.1 Don Berwick admires the NHS and has high regard for general practice, so we should listen to him carefully.1 He offers a manifesto for the NHS that differs from the usual tired exhortations to integrate, collaborate, and become patient centred. His argument about eras in medicine is attractive. Era 1 was the period of noble, beneficent, self-regulating professionalism that powered the NHS in its early days. In the compromises needed to launch the new health service in 1948, the political class conceded to the professions the authority to judge the quality of their own work.
Era 2 began when the variations in the quality of care, the injustices and indignities inflicted on people because of class, gender, and race, the profiteering and the sheer waste of Era 1, became inescapable. Era 2 introduced accountability, scrutiny, measurement, incentives, and market mechanisms, and has promoted discomfort and defensiveness among NHS staff, and feelings of anger, of being misunderstood, and of being over-controlled. Managers and the Department of Health in turn become suspicious, feel resisted, and can become either aggressive (creating a culture of bullying) or helpless.
Berwick has nine suggestions for helping Era 3 into being:2 stop excessive measurement; abandon complex incentives; reduce the focus on finance but increase attention to quality of care; reduce professional prerogative; recommit to improvement science; embrace transparency; protect civility; really listen (especially to the poor, the disadvantaged, and the excluded); and reject greed (it erodes trust). As we have tried to point out,3 some of these ideas have more resonance in the US than in the UK, but nonetheless Berwick offers us both a critique of the NHS and a programme of work to remedy its failings.
- © British Journal of General Practice 2017