We live in our own little boxes. Maureen Bisognano from the Institute of Healthcare Improvement , in her keynote address, told us we need to get out of our own little boxes if we are to improve healthcare. Quality improvement means breaking out of silos. She told us we needed to focus more on our patients asking not “What is the matter” but, “What matters to you.” She urged us to look at the organisation of healthcare citing the benefits from multidisciplinary rounds and the importance of teamwork in reducing mortality in intensive care. Everyone’s voice is important and it is essential that everyone, clinicians and nurses work together, a point echoed later in the day by Hugh Rogers from the NHS Institute for Innovation and Improvement, who described the difficulties of reconciling different tribes in the operating theatre: anaesthetists, theatre nurses, and surgeons. Maureen also encouraged us to look to the community—we currently focus most of our resources on the 3% at the top of the healthcare pyramid and only 3% of resources on the bottom 50%. Can we challenge the community to look at their own healthcare? She told a story:

Christian, a mechanic in Sweden, was a fit athlete who developed glomerulonephritis in his twenties and required dialysis. Frustrated by lack of control over his own healthcare, he asked to do his own dialysis. What a challenge to our medical model! But, facilitated by his medical team, he not only learned himself, but taught the elderly woman in the next bed, and went on to inspire the creation of an entire unit of patients undertaking their own dialysis. Patient empowerment at its best.  And why should patients not take full responsibility for their own healthcare? As Christian pointed out, he could now control the duration of his dialysis, care was safer in his hands, there was no variability in nursing or exposure to infection, and he was fully engaged with his own condition. It struck me that if patients can direct their own dialysis, then surely, managing other conditions like asthma, COPD, hypertension, and diabetes is possible.

Where are the problems?  A consistent theme through the day was that doctors can be a barrier—who are the surgeons most resistant to introduction of surgical checklists; who are the cardiologists most resistant to introducing emergency response teams; who is responsible for the my patient/ your patient problems in emergency patient care. Healthcare improvement—it’s all about behaviour change. But, we are not talking about the patients.

Domhnall Macaulay is primary care editor, BMJ