Only 12 months into Lord Darzi’s 10-15 year vision, it is no surprise that little real progress has been seen. But the forthcoming public spending squeeze could be a large and unexpected obstacle in the road to improved quality, safety and innovation.
- A number of initiatives proposed in Lord Darzi’s next stage review are under way or are in preparation stages, including quality accounts.
- It is still unclear how far middle managers and clinicians have taken the quality vision on board.
- Sudden economic downturn has set off a new debate over whether quality ambitions and cash savings will be compatible in the short term.
It is a year since Lord Darzi delivered his final report on the next stage review, High Quality Care for All, and the general consensus from health policy specialists is that we are pretty much where we would expect to be. Which is to say, one year into a 10-15 year strategy.
“I wouldn’t want to over egg the analogy but it is a bit like the old joke about Mao Tse-Tung being asked what he thought was the impact of the French Revolution,” says NHS Confederation director of policy Nigel Edwards. “He said it was too early to tell.”
It is of course early days but a lot of water has passed under the bridge since June 2008 - both with the ideas the surgeon turned health minister proposed and in the economy.
A number of the initiatives are up and, if not running, then certainly taking their first steps. Quality accounts are on the horizon, quality and innovation are being written into contracts via the 2009-10 operating framework and the commissioning for quality and innovation (CQUIN) payment framework. The NHS Leadership Council and the National Quality Board each have a membership and have met for the first time.
The strategic health authorities are moving forward on their regional plans, although at varying paces and with variable results. The addition to the reforms of practice based commissioning, world class commissioning, the NHS constitution and now transforming community services has made matters much more complex but, say commentators, the vision is becoming fact and is moving forward.
“The significance of Darzi is that he has recaptured the importance of professionalism and capturing the patient experience,” says Mr Edwards. “That will be his lasting contribution.”
Birmingham University professor of health policy and management Chris Ham says: “This is a long term ambition and we cannot expect quick results.
“We are seeing slow but steady progress and we are where you would have expected us to be by now.”
But the extent to which the vision of safe, high quality, innovative care has filtered down to clinicians and middle managers is not clear. Mr Edwards says there is some evidence that it is reaching the coalface.
“It has entered the language,” he says. “People are talking about the quality agenda and it has captured the imagination. Having said that, a year is a very short time for a major culture change.”
Health Foundation chief executive Stephen Thornton agrees that there has been a fundamental shift.
He says: “It has been fantastic to be working with the grain for once and not against it. For the first time, the conversations I have had with people have begun with the assumption that quality is the thing you put first.”
However, Managers in Partnership chief executive Jon Restell is not convinced.
“There is still a lot of work to be done around middle managers that needs to be developed locally,” he says. “If Darzi is going to be delivered then the quality and diversity of management at divisional level will need to be very high. At the moment the debate on leadership is very board driven, when what we need is a much broader debate about what it actually means to be a leader in the NHS.”
He is referring not just to the recent departures of several NHS chief executives but also to what kind of leaders will be encouraged in the NHS when the financial belt tightens.
He asks: “Will we see command and control type leaders to deliver cuts and results? Will that be what we need in practice, even if no one will say it in public? Will they be the ones that get on? If so, there will be some problems for delivering on Darzi.”
Professor Ham also wonders whether the forthcoming spending cuts could be make or break.
He says: “The big question mark for me is over whether Darzi’s vision will continue on a long term course, or whether the different financial prospects ahead raise serious doubts about whether the government will maintain faith in the Darzi vision.”
Like Mr Restell, he says: “You can imagine people at the Department of Health going back to a default position of command and control because the NHS cannot be allowed to rein themselves and their spending in.”
Implicit in this is a question mark over whether world class commissioning can really deliver.
“The recession has come two to three years too early for us to have confidence that PCTs and practice based commissioning can really rise to the challenge,” he says. “The current policies were designed during the expansion of the NHS. If the government gets its act together and makes some serious changes to payment by results and practice based commissioning as well as the regulatory framework for foundation trusts, it is possible to see how the Darzi vision can continue. But if the DH is very slow on responding, we may well end up going back to command and control.”
There has been no hint of this from the top so far, and commentators agree NHS chief executive David Nicholson is firmly on board with the quality, safety and innovation push set into motion by Lord Darzi. Indeed, he has made it clear he expects the NHS to deliver savings through safe, high quality services that are more cost effective.
Can the NHS really do this, though? “Up to a point, Lord Copper” seems to be the answer. Mr Thornton, for one, says tough choices lie ahead.
“I am not attacking David Nicholson, but I think we need to be careful that chief executives and board members do not jump on this bandwagon as a way to save the health service.
“Yes it is possible to make real cash releasing savings by focusing on quality and there is plenty of evidence to support that. But it is a long haul and it is very difficult to do. So let’s not presume that these approaches alone will sort out the problems looming in 2011.”
To put it bluntly, in 2011 PCTs will have less money than they do now. “There will have to be a serious look at health provider capacity,” says Mr Thornton. “Continuous improvement will not get us out of jail. We have to prepare ourselves for stripping out capacity and identifying savings.”
Can Darzi’s vision survive the recession? The only real answer to that right now is that we just do not know.
- HSJ is publishing a supplement on the Department of Health’s transforming community services programme on 9 July.
Delivering on Darzi
High Quality Care for All was more than a national policy. In 2008, all the strategic health authorities published regional visions setting out their own priorities and strategies. We asked where they had made the most and least progress over the last year. Not all replied.
AREAS OF SIGNIFICANT PROGRESS
- NHS South West. Waiting times for hospital treatment are now less than 13 weeks from referral for eight out of 10 admitted patients and nine out of 10 non admitted patients; 82 per cent of general practices now offer extended opening hours.
- The first seven polyclinics opened in London’s most deprived areas in April 2009. In January 2009, all London PCTs submitted plans for at least one polyclinic in their borough.
- NHS London launched a strategic framework and clinical leadership programmes to strengthen the expertise and capability of healthcare staff.
- NHS South Central has leadership training initiatives for more than 3,500 staff and talent management for 400 staff.
- NHS North East. A clinical leaders’ network has been established and a development and training programme created to ensure clinical leadership is sustained.
Stroke, heart attack and major trauma
- NHS London. A decision is expected in July on proposals to develop a network of specialist stroke and major trauma centres in the capital that could save over 500 lives a year.
- NHS East Midlands has made significant progress in identifying the best possible configuration of services and expects to commission them from 2010. Already Leicester General Hospital has a one-stop service for people who have suffered a “mini-stroke” and 24-hour availability of thrombolysis at its dedicated stroke unit and Lincolnshire Community Health Services has taken over the management of the accident and emergency department in Louth Hospital from the acute trust.
- NHS South West now has 80 per cent coverage for breast and cervical screening; retinal screening in diabetes has improved dramatically; and nearly all general practices now have learning disability registers.
- NHS South Central is implementing screening for bowel cancer and abdominal aortic aneurysm, the national vascular checks programme and supporting the roll out of NHS LifeCheck. This is supported by a £12m vascular health inequalities programme.
- In May 2008, NHS London’s 31 PCTs agreed to work together in six sectors, to commission acute services. They will be supported by Commissioning Support for London set up in April 2009.
- NHS North East believes its transformation system underpins a lot of what has been achieved. It promotes clinically driven improvement by improving quality, supporting innovation and increasing productivity through a shared understanding of individual, organisational and system behaviours required to deliver consistent transformational change.
Consistent high quality care
- NHS South Central implemented a clinical assurance process to ensure improvement support is available when significant variation is identified in clinical standards. This has led to a pilot to improve care and outcomes across the diabetes care pathway. The NHS South Central Patient Safety Federation is working to drive forward high standards of patient safety in all NHS organisations across the region.
- NHS South West has introduced bespoke service for people with chronic obstructive pulmonary disease in Somerset, and telehealth services in Cornwall and the Isles of Scilly.
- NHS London has developed plans to transform care for people with diabetes over the next three years.
- A strategic experience based project in NHS South Central is looking at capturing patient views and using them to influence how services are delivered.
Academic health science centres
- NHS London. Three of the five to be based in the capital.
Positive lifestyle changes
- NHS South West is finding it especially hard to make progress in areas where people need to change their lifestyle, for example increasing breastfeeding and tackling childhood obesity, teenage pregnancy and alcohol related admissions.
End of life care
- Most SHAs have some way to go in avoiding the need for patients to be admitted to hospital in the last days of life. However, NHS East Midlands now has a robust care pathway for end of life in Nottinghamshire.
Access to urgent hospital care and rehabilitation
- NHS South West wants to do more work to reduce delays in surgery for fracture and improve access to cardiac rehabilitation.
Helping patients navigate the NHS
- In NHS South Central work is still in the early stages with clinical directors for each of the clinical programmes expected be appointed in 2009-10.