After a routine physical exam, your family doctor explains that you have early signs of prostate cancer and refers you to the local hospital for testing and diagnosis. You are stunned, terrified and-after learning that it will take seven months to get into the hospital-enraged.
Welcome to Great Britain's National Health Service, the crumbling cornerstone of the British social services infrastructure. The prime minister has secured a commitment to increase funding by 35% over five years, but salvation of the 52-year-old public health system may come from clinicians remembering what it's like to be a patient.
The Brits have plenty to be angry about, including long waiting times-more than 1 million people in England are in queues for hospital treatment-and cancer survival rates that lag those in the U.S. Then there are more sensationalistic items such as general practitioner Harold Shipman, who has been convicted of murdering 15 of his patients with lethal doses of morphine, and reports of grisly occurrences, such as a hospital where seven bodies were left unrefrigerated in the facility's chapel for three days.
Now the public is even questioning the safety of treatments as common as childhood immunizations, says Barbara Stocking, interim director of the NHS' Modernization Agency. "The issue is that the public doesn't know who to trust anymore," says Stocking, whose newly established agency is charged with coordinating much of the NHS' service improvement work.
The NHS is on the front edge of a major restructuring effort. Prime Minister Tony Blair unveiled a reform plan in July 2000, supported by an earlier commitment to raise Britain's healthcare spending levels-now 6.8% of gross domestic product-closer to the 8% European average. The increased funding will pay to increase beds (2,100 more general hospital beds by 2004), facilities (100 new hospitals by 2010) and staff (nearly 10,000 more physicians by 2005).
Since the plan was announced, the change in beds, buildings and doctors has been understandably small. However, the change in waiting times between primary-care physician referral and testing for prostate cancer at West Middlesex Hospital in London has been dramatic-dropping from seven months to just 13 days.
"It isn't rocket science," says Helen Bevan, redesign director for the NHS' National Patients' Access Team, now part of the Modernization Agency. To bring about the changes at West Middlesex and other facilities like it in less than a year, Bevan says, they added no additional resources but simply redesigned the system from the bottom up. "Instead of looking at things in terms of resources or hospitals, we look at things from the point of view of the patients."
American healthcare quality guru Donald Berwick, M.D., credits Bevan's team with doing some of the best clinical systems restructuring work he's seen.
Berwick, chief executive of the Institute for Healthcare Improvement, Boston, has partnered with Bevan and others in England-including general practitioner John Oldham-who are reshaping the NHS from the inside out. Berwick brings with him strategies that have been core priorities during his 10 years of leading the institute: establishing teamwork among providers and rethinking systems to focus on the patient's experience.
Bevan's work examines the way providers work together. In one example, the Patients' Access Team redesigned how surgeons refer bowel cancer patients to caregivers involved in chemotherapy. By rethinking how information flows among clinicians, the team reduced the number of interactions between the surgeon and chemotherapist regarding the care of one patient from 26 "handoffs" to just one. The result has been that patients get their chemotherapy much sooner than before.
"About 90% of the time (when) things go wrong it is with the handoff," Bevan says.
Oldham, as head of the National Primary Care Development Team, also has led an initiative to restructure local doctors' offices and primary-care services. In what Berwick describes as "probably the largest collaborative-improvement effort in the world right now," Oldham is changing the patient flow in physicians' offices that serve about 7 million people in England.
The results of Oldham's pilot groups are impressive: All of those primary-care offices can schedule a patient to be seen on the same business day they call. Previously, waits to see the doctor were typically a week or more. Also, by implementing standardized primary-care protocols for treatment of coronary disease, Oldham says some areas have seen cardiac mortality rates drop by more than 40% in the past year.
What's the secret? "Winning their (providers') hearts and minds," says Oldham, who first read one of Berwick's articles 10 years ago and was spurred to change how he ran his own practice.
"This very focus of moving to the patients' needs and convenience is one of the biggest changes we have ever had in the NHS," Stocking says.