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Quality improvement in the US and UK
The improvement horse race: bet on the UK
  1. D M Berwick
  1. Correspondence to:
 D M Berwick
 Institute for Healthcare Improvement, 375 Longwood Avenue, 4th Floor, Boston, MA 02215, USA;

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The task of building the best healthcare system in the world is well started in the UK

Place your bets. Both the UK and the US are struggling to improve their troubled healthcare systems. Which is more likely to succeed? The two countries are strikingly similar in the problems they face, and equally dissimilar in their plans of action. I am a fan of both but, when bets are placed, my money will be on the UK.

The best problem list for either country is probably the one in the landmark 2001 report “Crossing the Quality Chasm” issued by the Institute of Medicine (IOM), a branch of America’s National Academies of Science.1 Summarizing decades of health services research and literally thousands of studies, the Chasm report recommended six “aims for improvement” as targets for the redesign of healthcare systems:

  • safety (reducing medical injuries to patients);

  • effectiveness (increasing the reliability of evidence based care);

  • patient centeredness (giving patients and carers far more voice, control, and competence in self-management);

  • timeliness (reducing waits and delays throughout the system);

  • efficiency (reducing the total cost of care); and

  • equity (closing racial and socioeconomic gaps in health status).

Rearranging the first letters, some organizations have taken to calling these the “S-T-E-E-E-P” goals.

Although the IOM’s report addressed only American health care, its findings—and especially the six aims for improvement—pertain well to the UK and the NHS. The ongoing massive UK effort to improve the NHS—launched as the so-called “Modernisation Plan” in 1997—has involved massive new investments (raising the total UK expenditures on health care from its starting place of about 6.5% of the GDP closer to the EU average of about 8.5%; compared with 15% in the US!) and the creation of focused strategic plans—National Service Frameworks—that lay out dozens of new targets and approaches to care improvement for a variety of important clinical areas. The National Service Frameworks speak much the same language as the Chasm report, with a good deal more precision.

The profile of relative importance of the six aims differs somewhat between the two countries. Equity and excessive cost are far more urgent problems in the US, while timeliness ranks at the top of the NHS improvement agenda. Problems in safety, effectiveness, and patient centeredness plague us both. Overall, however, both nations can with confidence focus on the same “STEEEP” list of aims as a worthy agenda.

Why would I bet on success in the UK over the US? The biggest reason is simple: the UK has people in charge of its health care—people with the clear duty and much of the authority to take on the challenge of changing the system as a whole. The US does not. When it comes to health care as a nation, the US is leaderless. An immense resource for progress in improving the NHS—the key resource, in my view—has been the consistent focus of government, emanating from the Prime Minister personally, on raising the bar for NHS performance. The modernisation process sought to establish accountabilities, structures, resources, and schedules in the NHS that no one at all is in a position to establish in the pluralistic, chaotic, leaderless US healthcare system.

No one is thoroughly happy in the UK with the NHS modernisation program to date; it has stumbled occasionally, as any project of that level of ambition must. But no honest observer can fail to credit the process with immense productive change, headed for real measurable successes in a behemoth system that could easily seem unchangeable. Several objective evaluations—of which the most important is that sponsored by the Nuffield Trust in 20032—find substantial gains underway in access, reliability, safety, and outcomes of NHS care. In the especially important arena of patient safety, the clear headed and courageous leadership of England’s CMO, Sir Liam Donaldson, and the founding of the National Patient Safety Agency as a national resource, may soon catapult England into international prominence in systematically achieving new and unprecedented levels of patient safety.

“Three tough issues lie between the good successes that are almost in hand and the great ones that could be.”

So, I will bet on the Brits. But I would offer even longer odds in their favor if a few large changes were made in the agenda for improvement of the NHS. Three tough issues lie between the good successes that are almost in hand and the great ones that could be.

Unifying improvement work at the health economy level

As an outsider, I would have thought that the globally funded, governmentally sponsored nature of the NHS would lead unerringly to sound development of community wide systems for the care of chronically ill people across the continuum of care. I would have thought that hospitals, community agencies, and primary care trusts—having, in effect, the same “owner” and “employer” (the public) and drawing on the same common pool of taxation—would work together seamlessly to assure flow, efficiency, integrated experiences, and common aims. But this is not the case. To my surprise, and to the UK’s loss, hospitals and primary care trusts at the community level—the so-called “health economy” level—remain too often strangers, uncoordinated, mistrusting each other, convinced of conflicting aims, and thereby failing to achieve the needed flow and coordination of care for patients in desperate need of both. The NHS’s long hospital lengths of stay and the feelings of disenfranchisement of chronically ill patients and carers, are only some of the symptoms of fragmentation.

The NHS will not achieve its full potential—the “STEEEP” goals will remain out of reach—unless and until the primary care trusts and hospitals at the community level are somehow brought more effectively into a common frame of planning, action, and patient care. Only a few local economies have shown success in this, due usually to nearly heroic leadership and hard work to maintain fragile coalitions. That plan is not robust enough for the nation as a whole. I do not necessarily recommend the rediscovery of the ancient “health authorities” as a vehicle, but some vehicle must be found to unify actions across the continua of care, or fragmentation will remain.

Achieving authentic patient centeredness

To a visiting American, consumerism and world class customer service seem a bit less developed in the UK than in the US. The same is true in health care. Viewed through American eyes, the modal British patient seems willingly more passive, and the modal British clinician habitually more controlling, than is probably best for either. The Chasm report uses the awkward term “patient centeredness” to denote the constellation of qualities of care that can give patients and carers power, knowledge, dignity, self-efficacy skills, respect for their diversity, and freedom of action. This is more than a political agenda (though it has political overtones); much sound clinical research shows that empowered, informed, activated patients tend to have much better outcomes and to use healthcare resources much more effectively than patients made helpless, silent, or passive by a system that takes too much control from them.

The NHS modernisation process still lacks a thorough commitment to patient centeredness of the type contemplated in the IOM vision. Perhaps the apparent British norms are just fine for Britain, and perhaps the pursuit of patient centeredness does not belong on the NHS agenda. But I doubt that. The next phase of development of a better NHS will go farther and faster, in my view, if stakeholders commit to a new level of control by patients and families of their own information and destinies in health care. It is important to know that British patients will not, in the first instance, demand that. They are trained too well. The question is not if they will ask, but rather if—once offered a new level of control and self-efficacy—they and the clinicians will come to appreciate the advantages of a new relationship that neither would have thought to request.

Linking the improvement of care to changes in professional education

It is as important to build a future as it is to heal the present. In health care the “future” refers to our young professionals—doctors, nurses, therapists, and managers—who will inherit the NHS when we rest. From the viewpoint of improvement, and in pursuit of the “STEEEP” aims, our young professionals are emerging ill prepared to help. The education of health professionals generally lacks focus on the skills in systems thinking, statistical thinking, measurement, cooperation, group process, teamwork, and pragmatic “real time science,” to name but a few disciplines that provide the foundation for effective citizenship in improvement. The result of missing this knowledge is a workforce that too often seems resistant to change and that lacks sufficient capacity to change the work it does.

So far, as I see it, the processes of change underway in the NHS lack effective connection to consonant changes in the education of young professionals. The omission is costly now, and will be more costly in the future as the workforce continues to be ill prepared to cope with—let alone to lead—a new, evidence based, reliable, patient centered, efficient, and safe system of care. That can easily change in the UK, but only with a totally new level of communication with and involvement of the agencies and leaders who are stewards of the educational systems—the Royal Colleges and others. Very promising changes are now underway in the relationships between the Royal College of Physicians and the leaders of the NHS, and these bode well for the future.


I do predict success for the UK in its efforts to build what can become the best healthcare system in the world—nothing less. The task is well started. These three adjustments—to organize care far better at the community level, to raise the bar on patient centeredness beyond what British patients may at first ask for, and to welcome and embed into the improvement process an agenda for change in the education of young professionals—will not be easy, but they are important enough to tackle hard and soon.

The task of building the best healthcare system in the world is well started in the UK