I am an optimist.
I think enormous improvements are possible for our publics, the people we serve but only
if leaders embrace the very, very difficult transitions that are necessary to modernise.
One out of seven dollars in the American economy gets absorbed by health care.
It means 2 things.
One is that it's a massive problem to change; turning the Queen Mary is easy compared to
taking this immense ship of technology and moving it toward the needs of chronic illness
and prevention in the communities.
A very hard problem.
The second part of the problem is economic which is 2.7 trillion dollars is a ton, now
we are at 17% of our GDP, Britain is at what ten and a half maybe not quite the same proportion
but you can sense here in this country the urgency that is felt.
Why is that?
It's because there are other uses for money.
In my State of Massachusetts not a single area of public investment is increased in
real terms in ten years except health care.
In America the enterprise of building a new bridge, if you will follow my metaphor, has
fallen dead centre into the worst episode of political polarisation in the memory.
I don't know the political environment here as well, there is an under cut in the civility
and that I still believe in.
Anyway you talk well so perhaps you discuss well I don't know but I tell you it's tough.
The English NHS through the UK as a whole economic pressure a debt in deficit affecting
health care, health care being questioned in terms of the amount of social opportunities
it has taken compared to other public and private sector investments.
The public in your case looking at its tax bill and wondering if it's getting value for
what it's being charged and a loss of real conversation in the face of headline news
and rhetoric that may not bear a lot of relationship to the complexity of reality, a confused public
wondering what's going to be lost and a profession who doesn't know which way to go is worried.
If you want to make something better you have to decide to do it, you have to have a 'what?'.
That is, you're going to need to decide to improvements.
Improvements are not automatic.
Entropy is automatic, decay is automatic.
To re-organise and be able to grow takes intention so there is a 'what?' to an improvement.
Rule 1 then you better have a 'how?'.
I mean yelling at yourself if the tennis ball goes the wrong place or a throwing your soufflé
out and just screaming that it's a bad soufflé it doesn't help, you need to change something,
you are going to need a way to change the recipe.
There is a myth about I think that the route science of health care improvement anyway
is economic you know set the carrot and sticks appropriately, put in correct contingencies
and all will be well.
I guess most people believe that.
I do not.
I think that perhaps a proper structure of incentives sets the stage for improvement
but that would work no more than teaching a child to play the Pathetiques or not on
the piano by giving him cookies when it goes well and hitting him across the head when
it doesn't.
That would be a very depressed child, he would cry, he definitely would not play the Pathetiques
now, you have to teach him how to play the piano and that's the nature of improvement.
To me it's a learning process.
My colleagues Tom Nolan and John Whittington in 2008 they came up with the idea that when
you are thinking about improving a large health care system, maybe a hospital or certainly
a nation, 3 goals are to be pursued at once in order to serve society.
They called this the triple aim.
The triple aim is first better care, safer care, more patient centred care, better care
more aligned with science, or equitable care, more timely care but say Nolan and Whittington,
"Wait a minute why did you have your heart attack, why did you break your arm, why are
you depressed, why do you have lung cancer?" and the answer is not that you didn't get
health care, health care is after the horse left the barn, it's the fix it shop.
The causal system lies outside health care, it lies inside society.
400 per cent more than in health care that's actually a number if you take the variance
and health status and you attribute it to different causes say a 100 points health variation
50 will be genes, not yet that alterable, there's 50 per cent over, 50 more points well
10 are health care and 40 are the rest of the causes.
So health care is one fourth as powerful as everything else I could list around nutrition
and activity and equity and justice and pollution and stresses in life and the third per capita
cost matters bring it down, bring it down, lower the cost, better care, better health,
lower cost.
This became a mission statement at Medicare under my leadership.
When I went there on day 3 I showed this to the 5,000 employees there, virtual tele-conference
and I said this is success for us.
I was offered the job of heading Medicare in Medicaid and turned it down.
I turned it down several times because it didn't make sense to me to leave IHI and go
there given the differences in the job.
Then I was in the atrium, the entrance hall to the Health and Human Services Building
in Washington to be interviewed and I saw this etched on the wall these words from a
famous American Senator Hubert Humphrey, he said the moral test of Government is how it
treats those who are in the darn of life, the children, those who are in the twilight
of life, the aged and those who are in the shadows of life, the sick, the needy and the
handicapped.
This is 100 million; this is one out of three of my compatriots of meeting the moral test
became very important to me.
I heard last year a quotation I don't know where it's from, perhaps someone can tell
me.
"We don't inherit the world from our ancestors, we are borrowing it from our children."
And when I read the morning papers now I wonder what we are handing them.
I am just showing you the orientation question in a complex environment fraught with conflict,
uncertainty, pressure, you better find your compass whether yours is the moral test or
your grandchildren or the triple aim I don't know that is up to you but you individually
you England, me individually, my country, better remember why or how makes no difference.
To provide a foundation that is capable of achieving better care, better health, and
lower cost at the same time unless we remember the changes the way we will be facing a very
vicious environment in America.
We will be cutting back on our safety net programmes; we will be taking money away from
citizens through tax dollars or through cuts in their pay because money has to go to health
care benefits.
We will be weakening the other investments we want to make with health care dollars like
teaching and research and more than that we are weakening the parts of society that can
benefit a better performing health care, we will weaken museums, we will weaken schools.
The NHS version of this I don't know.
I think from what I have seen through the years structural problems, your hospitals
despite repeated attempts to give power to the primary care system which wants to keep
the patient home.
Your hospitals are very much under incentive to stay rather busy and to make sure that
they have less of an incentive to build the continuity that we need.
Patient-centred care well we see Mid-Staffordshire a dramatic example where apparently cost pressures
became dominant and somebody forgot about the returning to the patient as focus of care,
everybody forgot.
And you continually re-structure all the time as if you can somehow find the correct number
of agencies and that just isn't just going to work people.
It's not the way to get there.
Your public I don't know.
Do you suffer in your public from the more is better theory when that's not true or the
reaction to the latest headline drives events instead of allowing for strategy?
I don't think this is a very good time for minor experiments, there is no time left in
a way I feel a sense of urgency for us that going to scale was going to matter.
You're closer than we are beginning with your solidarity that stretches back to 1948.
There is a window right now and I don't know whether it is three months long, three years
long, it's not ten years long and that is for the people who give the care to change
the care.
I think it's possible, could we do it, physicians, nurses, pharmacists, therapists, managers,
executives, boards, leaders of care to say "you know what?
it's on us, it's on us".
We must do it and we can do it and we will do it.