One year on: Darzi's long and winding road

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.”

Filtering down

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.

Bandwagon jumping

“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.