Simon Stevens on a good year for Darzi

Simon Stevens

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As wine experts will occasionally admit, it's hard to know how a new vintage will perform. Wines age, maturation takes time. And a decent bottle may be overshadowed by a later blockbuster year.

So as we take a first sip of Chateau Darzi, how to rate it? Darzi '08 is certainly smoother drinking than the concentrated and tannic radicalism of Blair-Milburn '02. That year's Delivering the NHS Plan still ranks as the most important inflexion point in NHS reform since Working for Patients in 1989.

So instead perhaps the new elixir recalls 1998's A First Class Service, the last white paper to focus on clinical quality, which created the National Institute for Clinical Excellence, a healthcare inspectorate and national service framework. But there are also hints of Chateaux Reid '04 and Hewitt '06, with their emphasis on prevention, primary care, long-term conditions and patient empowerment.

So it's not the content that makes Lord Darzi's review unique - sensible, evolutionary and worthwhile as it is. The key difference this time round is that the medium (Darzi) is the message.

So we have clinical engagement (the 2,000 helpers), clinical evidence (the footnotes on each page) and clinical legitimacy (the bona fides of the author). Lord Darzi is the living embodiment not just of a clinical polymath, but of a meritocracy. As The Sunday Times pointed out, there is something remarkable about someone who was born in Iraq to Armenian parents, of the Russian Orthodox faith, attended Jewish school, qualified in medicine in Dublin and then became an internationally renowned academic surgeon, British health minister and peer of the realm. And to top it all, he's one of the most thoughtful, sincere and unpretentious people you could ever wish to know.

So the ad hominem considerations are all favourable. What of the report's substance? Most of its suggestions are practical and workmanlike. It manages to avoid high-flown rhetoric and eye-catching stunts.

Of course, there are a few niggles. Locally agreed quality incentive overlays on the national payment by results tariff make sense. Leaving each primary care trust to try to work out which patient-harming "never events" to withhold payment for does not. Personal health budgets have the potential to be a powerful lever for change in community health services. "Personal care plans" could descend into tokenism. Affirming NICE's pre-eminence in standard setting is good. Inventing a new National Quality Board is less convincing.

New "quality observatories" may or may not add much. But bringing primary care contractors under the jurisdiction of the new Care Quality Commission will. The new vascular screening services should make a difference. But it's a shame that the opportunity wasn't taken to upgrade the pilot NHS faecal occult blood test bowel cancer screening programme to the more effective and cost-effective alternative of colonoscopy or flexible sigmoidoscopy. Integrated provider-commissioner pilots could work in limited circumstances, but they could also simply embed local provider cartels. Ditto the move of community health services from PCTs to social enterprises.

But that said, it's mostly good stuff.

Can the same be said of the draft NHS constitution? It mainly codifies existing rights rather than creating new ones. Its accompanying document says "to be meaningful, the constitution must provide means of enforcement and redress and not just consist of warm words or aspirations". Agreed. Yet judged against that test, more could be done.

Of the two substantive "new" rights that media coverage focused on, one - the right to receive NICE-approved treatments - was already implicit in legal direction requiring PCTs to fund positive NICE technology appraisals. The other - NHS patients' rights to choose a provider - has the potential to be an important and meaningful advance in patient power. But whether it is or not will entirely depend on how the forthcoming directions from the health secretary to PCTs are framed under section 8 of the NHS Act 2006. They need to be constructed robustly if patients are genuinely to benefit.

The constitution also says the NHS has a "social duty to promote equality". So the actions Lord Darzi signalled in his earlier report to bring new surgeries to deprived under-doctored communities will help. But it would have been good to have seen a certain date for ending one of the most inequitable aspects of primary care funding - the minimum practice income guarantee, which transfers cash from better performing to worse performing GP practices and from poorer areas to better off parts of the country. However justified it was in 2003, it is time to pull the plug.

And that gets to the heart of the matter. These are a worthwhile set of proposals that deserve support. The real question is whether they will actually be implemented. The latest Audit Commission report argues that the NHS reforms are "having a positive effect on the NHS" but that implementation has been too slow and uneven. Quite a lot of the good stuff from John Reid's 2004 white paper never saw the light of day after the 2005 general election. And even more of Patricia Hewitt's thoughtful 2006 white paper on primary and community services ended up on the cutting room floor, as deficits and budget crises crowded out the reform agenda.

Will the current political difficulties of the Brown government have the same negative impact on the Darzi proposals? No, argue the optimists, because this time round they have at least a degree of clinical support. Yes, argue the pessimists, because in the absence of external stimulus, there is little evidence the professions have volunteered to adopt many of the same commitments on clinical quality and transparency recommended by the Bristol inquiry seven years ago.

Maybe this time they will. But only time will tell. Just as it does with vintage wines.