The government’s plans to reform the NHS over the next 10 years were laid out in the Darzi Review.
In 2007, colorectal surgeon Lord Ara Darzi was asked to conduct the review on health services in England and consulted with strategic health authorities and clinical pathway working groups to set future priorities.
Darzi suggested that while the NHS was two thirds of the way through its modernisation programme - as set out in the NHS Plan in 2000 - further steps were needed. While the health service had increased capacity and driven down waiting times, quality and outcomes needed to be improved.
Other aims of the Darzi review included ensuring services were better joined up, care was more accessible and integrated, and services provided more patient control, choice and local accountability. There’s also been a drive to put clinical decision making at the centre of the reforms.
As the Darzi review took shape it echoed the themes of the white paper Our Health, Our Care, Our Say - particularly on choice, personalisation and community services - but there was a change in how it would be delivered. It was no longer about top down targets with a focus on outputs, but about quality and local determinism.
The key devices to achieving this are improved information on clinical performance, greater choice and control for patients and strengthened incentives for providers.
High Quality Care For All
The final report High Quality Care For All - NHS Next State Review Final Report was published in June 2008. It sets out how the NHS should move from centrally driven, target based management to one of empowered local services focused on quality as well as activity.
Darzi’s focus on raising quality
One of the key drivers of change will be a range of local quality indicators that will enable clinicians to benchmark and improve their performance. Areas measured will include mortality, complication and survival rates and patients’ views.
Financially, funding formulas and contract payments will increasingly be linked to quality outcomes. All providers - NHS, private and third sector - will be required from April 2010 to publish Quality Accounts explaining how they made a difference.
Clinical Excellence Awards will be more focused on quality improvement. New awards conditional on clinical activity and quality indicators, and encourage clinical leadership and innovation.
The review proposed the new NHS Constitution, which spells out its principles and values and enshrines patient rights.
Patients will have a greater choice of GP practice, and ‘choice’ is a tenet of the constitution.
Patients are now guaranteed access to the most clinically and cost effective drugs and treatments. All patients will receive drugs and treatments approved by NICE where the clinician recommends them. NICE’s appraisals process is to be speeded up. Some have criticised it for being toothless.
In his first major speech as health secretary Andy Burnham outlined the developing system of accountability in the NHS, initiated by Darzi, and founded on a smaller number of agreed patient outcomes and fundamental rights. The NHS Constitution will sit alongside service guarantees linked to a minimum set of standards - rather than lots of volumetric targets - that will need to be maintained.
Services closer to home
Darzi had just produced his 10-year plan for the reorganisation of the NHS in London when he started his review. The London plan proposed the creation of larger specialist centres for the treatment of conditions such as stroke and heart attacks. This was combined with a network of 150 GP-led health centres providing a combination of services traditionally offered by GPs and district general hospitals.
Many of these ideas were also reflected in the interim report Our NHS Our future: NHS Next Stage Review
published in Oct 2007. This report included recommendations to introduce MRSA screening for hospital admissions and create 100 new GP practices in deprived areas.
It also controversially proposed to create 150 new health centres around the country which would provide extended range of services and longer opening hours. Polyclinics are intended to improve access and better integrate primary care practitioners with diagnostic and specialist services.
They are intended to reflect local needs and priorities, and be open from 8am to 8pm every day to fit with people’s lifestyles. Any member of the public can walk into a polyclinic regardless of which local GP service they are registered with, and people will be offered the opportunity to register at these new facilities.
However there are concerns that, despite a lack of clarity over their purpose, they are being rolled without being piloted.
It’s looking increasingly likely that polyclinics will only be established in London.
Personalised services in Darzi review
When consulting for the review, Darzi commented: “Patients have told me that they still sometimes feel like a number rather than a person…they lack ‘clout’ inside our health care system.”
Along with clarifying and strengthening patients rights, and giving them more choice over who treats them, the review also gives them more power over how they are treated.
Everyone with a long-term condition will have a personalised care plan and personalised health budgets will piloted, with direct payments used where possible.
Andy Burnham described personal budgets in his first major speech as the “ultimate expression of power and influence being handed down to the individual patient”. The DoH is due to pilot them among 5,000 patients with chronic conditions. “These pilots will give patients the power of the purse strings: making decisions with the help and guidance of GPs or consultants that directly affect their own budget is spent.”
A more preventative approach to public health
The NHS, through partnership working, will focus on improving health alongside treatment. Every PCT will commission comprehensive wellbeing and prevention services in partnership with local authorities. And there’s a new coalition for Better Health with voluntary agreements between the Government, private sector and charities to improve health. GP’s Quality and Outcomes Framework is to be improved to provide incentives for maintaining health as well as providing care.
Better guidance and regulation
The Care Quality Commission will have new enforcement powers to improve safety and reduce healthcare associated infection.
NICE will be expanded to set and approve more independent quality standards. A New National Quality Board will set priorities and feedback to government.
There is new emphasis on innovation and fostering an enterprise culture. Strategic health authorities will be under a statutory duty to promote innovation and regional innovation funds will be launched to invest on a commercial basis in good ideas. There will be a pilot programme of ‘health innovation and education clusters’ to stimulate partnership working between clinicians, universities and business.
More support is promised in the Darzi review for clinicians who want to move out of the NHS to set up independent social enterprises. Their pensions will be protected. Integrated care organisations will also be piloted, bringing together health and social care professionals together. There is also a pledge to reinvigorate practice-based commissioning and give greater freedoms and support to high-performing GP practices to develop new services for patients.
Clinical leadership will strengthened, with medical directors and quality boards featuring at regional and national level.
Darzi review update – one year on
Darzi launched a new set of proposals in High Quality Care For All: Our Journey So Far, which charts the progress of the Darzi Review one year on.
Clinical budget ownership is to be extended to hospital doctors and nurses, with the aim of promoting entrepreneurship and innovation in service delivery.
Two “obsolete” clinical targets are also to be removed: the 13-week outpatient and 26-week inpatient performance targets. A review into other targets was also launched.
A voluntary peer review accreditation system will also be introduced to assess the standards of clinical teams and create competition among clinicians to improve. The royal colleges are currently developing a consistent approach, and it will be overseen by the National Quality Board.
Lord Darzi resigned, in July 2009, returning to research and surgery. While the public reason for his early departure was his concern for his patients, it’s been suggested he found the culture of Whitehall challenging.