Profiles in Improvement: Lord Nigel Crisp, IHI Senior Fellow

Crisp_Nigel_Sep11.jpgLord Nigel Crisp is an independent crossbench member of the House of Lords in the UK and works mainly on international development and global health. He is Strategic Advisor to the CEO on Global Health and a Senior Fellow at the Institute for Healthcare Improvement. The former Chief Executive of the National Health Service (NHS) and Permanent Secretary of the Department of Health, he led major reforms in the English health system. Prior to joining the NHS, he served as Chief Executive of the Oxford Radcliffe Hospital NHS Trust. He also co-chaired an international Task Force on increasing the education and training of health workers in developing countries, and subsequently co-founded the Zambia UK Health Workforce Alliance in 2009 to implement some of the Task Force's proposals. He is an Honorary Professor at the London School of Hygiene and Tropical Medicine, and an Honorary Fellow of St. John's College in Cambridge and of the Royal College of Physicians. He chairs or is an advisory board or trustee member of numerous organizations, including Sightsavers International, African Centre for Health and Social Development, the Global Health Programme at the Aspen Institute, and RAND Europe, among others. He is author of the book Turning the World Upside Down: The Search for Global Health in the 21st Century.
Q: In your former roles as head of the NHS and the Department of Health in the UK, you are no stranger to thinking about how to make big systems of health care delivery better. What type of leadership is needed to instigate change at this level and to bring others along with you?
Yes, I was Chief Executive of the National Health Service in England and head of the Department of Health in the UK. I was responsible for the biggest integrated health system in the world — indeed, it’s the fourth biggest organization in the world. The only bigger organizations are the Chinese army, the Indian railway, and Walmart. The NHS had 1.4 million staff and an annual budget of $160 billion. So roughly, in my six years, I was responsible for spending about a trillion dollars.
To lead change on that scale, you need a few things. First, you need a vision and a plan. We had a very coherent plan called the NHS Plan, which focused on delivering specified improvements in the NHS: reduced waiting times, reductions in avoidable deaths (by “avoidable” we meant death from things like heart attack and stroke before the age of 70), and a whole range of other targets we set for ourselves.
Second, you need the right people to carry out the plan — not only the stakeholders, but also a guiding coalition of leaders. Throughout much of my time in the NHS, I think there were nine people at the top, from the Prime Minister to me, who were coherently pursuing this same plan. And it was very important that we were going in the same direction.
Third, you need to support the people in delivering on the plan. At the NHS, we had a two-pronged approach. First of all, we made people accountable, so people knew what they were expected to deliver, and we held them to account. At the same time, we also used techniques that we learned from IHI (this is in 2000), particularly from Don [Berwick] and Maureen [Bisognano], who were working with the NHS; things like identifying best practices and using the IHI Breakthrough Series Collaborative model to spread those practices around the country. So, for example, we had action teams — groups of people focused on making improvements — on orthopedics and on cardiac surgery. And this structure helped us to dramatically reduce waiting times for cardiac surgery, for example, like we never had before. Previously, there had been instances of people waiting more than a year for cardiac surgery, and we reduced that time to a very small number of weeks, or less than that, within a relatively short time.
Q: Your more recent work has focused on global health. How do you define “global health” and what does it mean for quality improvers everywhere?
When I resigned from the NHS, the Prime Minister asked me if I would look at what more we could do, in the UK, to support health improvement in poorer countries. I subsequently created a report, called Global Health Partnerships, with a series of recommendations.
During this work, I discovered — was surprised to discover — how much people in rich countries can learn from poorer countries. Everyone has something to teach and everyone has something to learn. And, when I think about “global” I think about all the ways we’re interdependent. The same diseases can attack us all. In the 14th Century it took three years for Black Death to get across Europe. More recently, it took three days for SARS to get around the world.
We know we’re all vulnerable to the spread of disease around the world; we’re in it together — we’re all part of the problem and the solution. So, for me, when I talk about “global health” I mean all the things that affect us all: resources, staffing, knowledge, and learning from each other. The vulnerabilities of the poorest countries are our vulnerabilities too.
And I don’t make a distinction between “developing” countries and “developed” countries. I think that’s a rather patronizing distinction. It sort of implies: we’re developed; we know where we are. Actually, our health systems, in rich countries, are pretty poor, aren’t they? If anyone needs fixing, we need fixing just as much as health systems in poorer countries need fixing. The problems may be a bit different, but there’s a lot of overlap.
So, I think we should be looking at health issues as they affect the world as a whole, and while the manifestation in Malawi may be different from Manhattan, there are things that both can teach the other.
Q: What brought you to IHI, and what will you be doing in your role with IHI?
I got to know Don [Berwick] and IHI from our work together in the NHS. After I retired, I continued talking with Don and Maureen [Bisognano] about global issues, and this seemed like a good way for me to contribute to IHI’s future endeavors. IHI’s had a fantastic past, but it’s also got a fantastic future. And it’s a privilege to be part of shaping that.
I’m helping IHI to develop from being primarily an American organization that is working a bit abroad into one that actually sees and operates more globally than it has done before. Over the years, IHI has grown globally in its ambition and in its work, but it hasn’t grown globally in its strategy. It is not, yet, a significant global player.
What we need to be thinking about is how to create a structure that embodies the next phase of development of IHI. I will be recommending a strategy that is very much respectful of others and respectful of “all teach, all learn,” with the knowledge that we can learn from poorer countries which — because they don’t have the same resources, vested interests, and “baggage” of richer countries — can sometimes innovate much more. But we can also teach. I believe that IHI with its very particular methodologies can contribute an enormous amount globally.
Q: What does your work involve now?
We’re starting to change the direction. I’m helping IHI think through its own future — to consider how to make IHI's international work more coherent, fit better with IHI’s ambitions, and identify how IHI can have the biggest possible impact in the world. That will be a significant impact in America, and it will also be significant elsewhere.
So, I’m spending a few days a month at IHI and I’ve also visited South Africa to get more acquainted with IHI’s projects there. I’m also talking to people in Europe, finding out what people in other parts of the world think of IHI.
Q: What do people think?
I think the most interesting aspect has been to learn that the thing that is most highly rated about IHI, though my analysis is not totally scientific, is IHI’s ability to convene — to bring together a network of people and organizations to talk with clinical innovators, not just in the US but around the world. That ability to bring people together to develop new ideas with IHI is the most highly rated aspect of IHI activity, and one of the things we should build on for IHI’s future strategy.
Q: What do you see when you look at health care in the US?
I see some wonderful stuff and an absolutely appalling system. A very expensive way, as someone said, to deliver poor health care. But, what I also see are all those highlights. I see fantastic people, individual fantastic services, and things that are as world-leading as you’d expect. But somehow, when you put it all together, it’s not serving its population well. It’s a great burden on the US economically, which spends twice as much as the UK as a proportion of GDP to get a poorer result, as measured, for example, in average life expectancy. I think that is clearly a major problem, and IHI can help with that. But changing a system in which one in six jobs in Massachusetts, for example, is in health care — you’re changing a system that is full of vested interests; you have extraordinary vested interests in this country in health care. But you also have some great stuff!
Q: What are you most excited about for your time here at IHI?
In poorer countries, the thing that people talk about in policy terms is strengthening health systems. Yet, in the UK and in the US, the health systems are far too strong. In these systems, health care consumers sometimes get forced into doing things they don’t necessarily want to do. They force an individual into hospital rather than getting his or her treatment elsewhere, for example.
The way that IHI thinks about problems in systems terms and in quality improvement terms is enormously valuable there. We need to spread that understanding of systems improvement and quality improvement in poorer countries as well as in richer countries because we are so interconnected. That’s most exciting to me.
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