Darzi review will be a success when it causes managers grief

Richard Vize

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Lord Darzi's next stage review has been met with a remarkable degree of support. The few critics have failed to shoot any substantial holes in it.

Even the Daily Mail struggled to level charges.

Although at first glance the review appears to be a mosaic of evolutionary changes rather than a Big Idea, closer inspection reveals that it is a new world. Publishing comprehensive data on clinical effectiveness and outcomes has the potential to drive profound quality improvements, and will transform the management landscape of the NHS.

The constitution is a surprise hit. A document that might have been filled with platitudes is instead populated with commitments to patients and staff that strike a chord.

In HSJ's survey of staff views on the health minister's plans there was an overwhelming message that the constitution reflected the right values for the service.

The difficult part will be translating it into action. The positive response identified by HSJ means it is at least acceptable to staff, but that is a long way from it becoming a tool to empower patients. Our survey reveals widespread doubts about whether patients really will get more clout.

Perversely, the moment when the constitution should be judged a success is when it starts to cause managers serious aggravation. Once lobby groups and service users begin to wield it as a weapon to challenge practice and policy, we will know the constitution has come of age.

The review tackles the issue of management incompetence. Jonathan Fielden, chairman of the British Medical Association's consultants and specialists committee, is among those who have called for managers to face the sanctions of a robust competence regime similar to the General Medical Council.

While Lord Darzi stops short of full force regulation, he has opened a debate on how recruitment and assessment of managers can be framed to remove those undermining the service.

This is a necessary step which will promote excellence and protect NHS management from the reputational damage of failing to be seen to weed out poor performers - pay-offs and back-door departures may be less bloody but they do not maintain public confidence.

The plan to identify and nurture 250 top leaders - clinical and non-clinical - is appealing but flawed. The number seems parsimonious compared with the size of the service and the leadership challenge, and having the NHS chief executive post at its head runs the risk of recruiting a cadre too defined by a Whitehall view of what constitutes leadership, with insufficient room for mavericks and innovators.

They are the people who will drive the most inspiring developments and force the cultural change Lord Darzi requires by actively subverting central control to focus on their patients.

In the short term the biggest winners are the strategic health authorities. Leadership development, innovation and workforce planning give them a renewed clarity of purpose. Their success should be judged on exercising their considerable powers without trampling on provider autonomy.

Analysing the wealth of new quality data will be a complex and delicate task; working through the clinical and system implications of performance variation will require management skill and clinical collaboration of the highest order.

And managers must never lose sight of the fact that drawing the wrong conclusions could be catastrophic for a trust - careers and reputations might be broken on the wheel of misdiagnosis.

The implications for managers of the new world of outcomes data can scarcely be exaggerated. As I once heard a teacher say when explaining quantum physics: "If it hasn't blown your mind you haven't understood it."