4 October 2007 - Summary

General themes of the report

Professor Lord Darzi distances himself from his political role and writes 'as a doctor' in this 56 page report which gives us a taste of his vision for the next 10 years of the NHS. The full vision and a plan for its implementation will be published next June. This report is peppered with his personal experiences of clinical practice and emphasises that the great improvements over the past 10 years have been due to the hard work of NHS staff. He emphasises that his vision has been, and will continue to be, shaped by users, providers and commissioners of care, as well as the expectations of the public.

Darzi does not want to change the direction of reform and believes it should be seen 'through to its conclusion'. He estimates that we are currently 'two thirds' of the way through the reform process that began in 2000. However, rather than incremental change at the current rate, he advocates an acceleration towards an ambitious vision of a patient-centred, clinician-led, locally driven NHS.

Core of Darzi's vision for the next stage of reform

While not advocating changing funding or structure, Darzi strongly pushes for a shift in the focus of reform in two ways:

• moving the locus of control from the centre to local communities, in particular towards clinicians and patients themselves - the centre should 'support local change not instruct it'
• moving the focus from the quantitative business of targets to the qualitative business of a 'relentless' focus on improving the quality of care and the quality of the patient experience of care.

Achievement of more ambitious levels of change involves tackling the negative perceptions of the public, the disillusionment of staff, and giving more 'clout' to patients. These three actors in healthcare are at the centre of his thinking and recommendations.

Achieving the vision: immediate actions and longer term considerations

The report is structured into five areas for improvement: equity, personalisation, outcomes, safety, and local accountability. These five will be tackled by the groups of stakeholders looking at the eight types of care for the June 08 review: mental health, maternity, children, planned care, emergency care, end-of-life care, prevention and promotion, and long term conditions.

For each of the five areas, progress so far is outlined, and then steps for immediate action (before June 08) and issues to explore further in the main review are articulated.

1. A fair NHS - equity of access, outcomes and treatment quality

For immediate action:

• health inequalities strategy (already announced by Alan Johnson) .

For main review to examine:

• concerted action across government to address the social determinants of health
• how to close inequalities gap (currently worsening) in access and outcomes.

2. A personalised NHS - tailoring care to patient needs and preferences

For immediate action:

• 100 new practices to 25% PCTs with worst provision (eg low numbers of GPs, poor outcomes) - with up to 900 GPs, practice nurses, and other primary care professionals
• new money for 150 GP-led health centres which do not require registration and which provide a wide range of services including pharmacy, GP, social care, diagnostics. These will be open 7 days a week, 8am-8pm
• opening up the primary care market: at least half of practices must open each weekend or one night during the week; if they do not, PCTs will be given money to commission services from the independent sector or GP federations.

For main review to examine:

• a vision and strategy is needed for primary care in the longer term, including a re-think of incentives, examining different models of care, designing outcome measures, and mechanisms for rewarding popular practices, expanding choice
• a new 3 digit number for non-urgent problems
• integrated care through patient pathways designed from the point of view of patient experience and convenience - the concept of 'one stop care' should be explored - minimising outpatient visits to hospital, minimising number of visits to health centre etc. Incentives should be designed to encourage collective accountability for pathway outcomes
• give people with long term conditions more choices; use individual budgets to help them design their own support package

3. An effective NHS - improving outcomes and harnessing the latest techniques and technologies

A University of Birmingham study across several common chronic conditions revealed that less than 50% of patients were receiving 'optimal treatment'. Darzi wants to change this and says that we should 'move away from cost containment and seek to harness innovation'.

For immediate action:

• establishment of Health Innovation Council to help demonstrate how innovation can improve outcomes
• explore the shape of a national standard quality framework to allow for quality benchmarking and to aid patient choice - this should give great weight to patient-reported outcome measures.

For main review to examine:

• how to shift focus to National 'Wellbeing' Service - through engagement of people earlier in their disease - perhaps through regular 'life checks'
• how to overcome 'NHS reluctance' to adopt new products and techniques.

4. A safe NHS - stepping up infection control powers

Immediate action:

• more power to matrons and clinical directors to control HCAIs and increased requirements for boards to monitor HCAIs
• a duty on chief executives to report MRSA and C Diff
• powers of inspection and intervention in infection control (and punishment through fines) for Ofcare
• penalties may be built into commissioning contracts for financial penalty or reward depending on performance on HCAIs
• establishment of single reporting 'hotline' for frontline professionals to report safety incidents - 'Patient Safety Direct'
• local patient safety action teams will be accountable for safe care.

5. A locally accountable NHS - reconfigurations should be based on clinical case for change

Immediate action:

• guidelines sent out at end 07 to outline more stringent criteria upon which reconfigurations can be undertaken locally - they can only commence if independent clinical review recommends it based on the clinical benefits it will bring
• guidelines for streamlining process of local reconfiguration will be issued including timescales
• likely that PCTs will need to extensively use FESC due to variable commissioning skills.

For main review to examine:

• group to examine feasibility and desirability of an NHS constitution as mechanism to enshrine NHS values, increase local accountability, provide a transparent process for arbitration and decision making, and to define the rights and responsibilities of staff and patients
• how CfH can deliver real clinical benefits
• what support is needed for effective local change
• overhaul workforce planning and link it with service planning
• strategy for leadership development (group led by David Nicholson).