HSJ talks to Gordon Brown and Lord Darzi

Gordon Brown and Lord Darzi

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While the past 10 years of NHS reform were designed to increase capacity, the next task is to increase quality and personalisation and give more power to clinicians and patients. Gordon Brown and Lord Darzi explain their plans to Richard Vize

Lord Darzi has grasped in a year what many full-time politicians never grasp in decades: you cannot change behaviour in the real world from Whitehall.

"I know - being in Whitehall for near enough 12 months today - there is no way in my role, in my office, in my job, I could change the behaviour or the service that I provide in St Mary's Hospital on a Thursday and Friday."

The health minister and surgeon was talking to HSJ with prime minister Gordon Brown a few hours before the review that bears his name was unveiled in Parliament this week.

The setting, Leatherhead Community Hospital in one of the most affluent parts of Surrey, was chosen because it represents three totems of the Darzi review: a commitment to expanding community-based medical facilities; putting power in the hands of clinicians; and the prime minister's passion for the social enterprise model of care provision.

The hospital is run by a not-for-profit company controlled by its clinicians and provides therapy and nursing facilities. It holds a specialist personal medical services contract with Surrey primary care trust.

After years of criticism that NHS policy was under the sway of politicians at the expense of clinicians, Mr Brown is at pains to ram home the message that this time clinicians and even patients have been in the driving seat: "This review is a year-long project involving hundreds of clinicians and members of the National Health Service right across the country. It has been listening to the voice of not only doctors and members of staff of the NHS but patients.

"The centrepiece is what can give the quality experience to the patient themselves. All the proposals of Lord Darzi are built around how clinicians can be empowered to give that high quality service, how the resources of the NHS can be better used at a local level so that quality is uppermost in people's mind, how we can give new incentives around the country so that people can pursue this aim of a high quality service."

The constant refrain is that, after record investment, the NHS now has the capacity it needs; the relentless focus now must be on quality and personalisation: "We're now ready to move to the next stage of the National Health Service's development," Mr Brown says. "A service that is more personal to people's needs and a service that is about prevention, as well as about cure, a service that empowers the clinicians so that they can make the best contribution that they want to make to the development of healthcare."

The "postcode lottery" in access to drugs approved by the National Institute for Health and Clinical Excellence has undermined public confidence in the equity of the service, fanned by newspapers such as the Daily Mail. While some of the more impoverished primary care trusts may blanch at the cost, Mr Brown is clearly pleased the Darzi review has moved to kill off the issue by giving patients the right to get approved drugs.

"We're seeing an end to the postcode lottery in the provision of drugs through NICE, so that people know that when a drug is approved by NICE it's available in all parts of the country. These are big changes that are happening as we prepare the NHS for an even more successful next stage of its development."

Talking about quality

While the government is now moving away from the target culture, it makes no apology for having needed to restore public confidence in the health system by wiping out waiting lists counted in the hundreds of thousands. In explaining how his review will change the way the government runs the NHS, Lord Darzi stresses that progress on issues such as waiting lists over the last 11 years means the focus can now shift.

"We've got rid of the numbers. We've got rid of waiting lists, we've got rid of waiting in A&E departments. We're talking about quality - that is where we're heading. And we have the investment."

He adds: "What brings me to work in the morning is to come in and provide better quality care." From another mouth such words might have been no more than a pious sound bite, but Lord Darzi's record of clinical innovation and challenging orthodoxies demonstrates he does exactly what he says. In his recent appearance on Radio 4's Desert Island Discs, he took a swipe at medical "laggards" who are slow to change, but he believes that his plan for pushing power away from the centre and focusing on quality will bring out the best in staff.

"You know and I know we have the best talent when it comes to staffing the NHS. Having the money and talent, what we need to do is really converge all of our efforts - whether you're a doctor, you're a nurse, you're a manager - in focusing on what matters most. What matters to you when you're ill - the most vulnerable part of your life - is quality. You're looking for quality as a patient. That is what energises staff and that is what this whole review is all about."

There is a sense of Lord Darzi struggling to admit to himself that, although he is first and foremost a surgeon, he is now also a politician. But he is justifiably forthright when describing the unique nature of his appointment: "The very bold, courageous attempt of appointing a clinician out of the health service to come and lead a review - that in itself was the biggest statement to make. And since then the whole review has been local, has included 2,000 doctors, nurses, managers, social care workers, carers, all across the country in 10 regions. That is what's different. We have never, in 60 years - I've looked at every history book on the NHS for the last 60 years, whoever the author has been - we have never done anything like this.

"And what we've done is let the clinicians out there, throughout this review, really decide what is the care they wish to provide, but in partnership with patients. That's what's newsworthy - it's a partnership at a local level. It's no longer national - we've done our bit."

Lord Darzi rejects the suggestion that, because of the regional focus underpinning his review, power will shift to the strategic health authority instead of the front line: "The vision may have been constructed at 10 regions [but] I've made it very clear every SHA needs to push this vision down. It needs to be much more grounded. It needs to get to places like this hospital, it needs to be within GP practices, it needs to be in hospital wards - that is where the debate, that is where change, happens."

Passion for enterprise

One of the first health policy issues raised by Mr Brown's accession to power was the new government's attitude to the market and the private sector. Number 10 is sensitive to any perception that he is tilting away from using the private sector and Mr Brown is keen to stress that it will be free to score on the level playing field of quality: "We've got to be the best service. It's about quality, it's about excellence. So we will have a range of providers and where the best can do the best job, we will use them."

But his passion for staff-driven social enterprise soon bubbles through: "Equally, as Ara Darzi is saying, the real dynamism in the National Health Service comes from local staff - from the nurses and the doctors and members of the general staff.

"As we're seeing here in this particular practice, they feel empowered and they feel they can make the patient experience so much better by taking into account their needs and listening to their levels of satisfaction - trying to provide a service at the time that is most convenient, in a place that is more convenient, and with a range of new technology that makes life a great deal easier. We're seeing it here, where there's an 800-strong group of nurses and others who are working together to improve the care in the community and in this hospital, people who are really now saying that they're more satisfied with the service.

"These are the sort of opportunities that are being made that take the patient into account and make the patient feel that they are being listened to and are not just a number. I think social enterprise has got a really big role to play. So it's whatever empowers the staff and allows them to deliver a better service to the patient. And I feel that there are very many examples of good practice by social enterprise."

Driven by a mix of responding to mounting evidence of public health crises such as obesity and a political commitment to begin tackling health inequalities, this government is pushing hard the idea of the NHS being as much about prevention as cure. The rhetoric bears little relation to the distribution of resources, and there is no clear road map of how this transformation will be achieved, but the prime minister's commitment to the principle is clear: "I think people can look forward with confidence, not only to a health service that is better at curing disease and illness, but a health service that is better at preventing health problems. That is really how people will look at the health service in the future: more spent on check-ups, more spent on screening, more spent on preventative vaccines so that people are in a better position to enjoy good health and not just helped when they have ill health."

Describing how reform of the NHS fits into his vision for public services, Mr Brown says: "Now the emphasis [is] on empowering the user - putting the patient or the pupil or the student or the consumer or the citizen at the centre of the delivery of a service. We're empowering the users so that they feel that they have more voice, more choice, more control over the services delivered. And often that will mean giving them a personal budget, having satisfaction surveys of what users are thinking of the service, so they can influence the next stage of its development.

"And the second thing is empowering the professionals, because we have this enormous talent - this pool of great talent in the health service and all the other public services. That is the way forward for the public services - a more strategic role for government, a more direct role for the patient, for the pupil, for the teacher, a more empowered position for the professional."