At the heart of Lord Darzi's next stage review is a commitment to deliver a step change in the quality of service provided to patients.

This commitment covers not just safety and clinical effectiveness but also the more challenging objective of improving "patient experience", specifically in relation to compassion, dignity and respect.

However, the optimism around the impact of the report may have become an excuse for avoiding an honest discussion of why a service that has received additional resources on a hitherto undreamt of scale over the last decade is not already delivering the quality of service the review seeks to achieve.

To be sure that the implementation of the review does not become yet another exercise in rearranging deck chairs, NHS leaders need to be more honest about the underlying problems the review intends to address.

Widespread problems

Lord Darzi was clearly given a brief by ministers to get the NHS focused on quality - not out of a desire to make an already good service better, but out of a real concern that too much of what the NHS delivers in patient experience is still mediocre and at times rank bad.

Despite the upbeat spin on the results of the 2007 Healthcare Commission patient survey, there was evidence of widespread problems:

  • one in five patients reported that they were not always treated with respect and dignity, rising to one in three in the worst performers on this measure;

  • one in five patients who needed it did not get help with eating, rising to almost half in the worst performing hospitals;

  • four in five patients reported a delay in the response to the nurse call button;

  • almost half the respondents reported problems in finding a member of staff to talk to about their anxieties;

  • almost half the patients felt there were not enough nurses on duty.

Other telling evidence of the widespread existence of poor patient experience can be found in the annual staff survey. In the four years since the 2003 survey, the number of staff who say their trust gives top priority to patient care has remained stubbornly below 50 per cent.

There is little doubt that government concern over the quality of patient experience in the NHS will have come from feedback from constituency MPs based on harrowing individual stories.

In the face of this, there must be a question as to whether foundation trusts, world class commissioners, the Darzi reforms, polyclinics, patient choice and provider competition will really address, any time soon, the fundamental obstacles to improving patient experience, especially for older, chronically ill users of the service.

People, not organisations

In the private sector, poor service leads to loss of business and loss of jobs. In the NHS, the managers get sacked but the consequences of poor service rarely filter down to a clinical workforce that still assumes it will always benefit from public demand (reinforced by politicians on all sides) to retain local services.

Lord Darzi's proposals for publishing quality metrics, getting patient feedback, and imposing financial penalties for poorer performers continue the philosophy that organisational penalties are the key to driving up performance. On paper, it could make a difference, but in practice it could become another bureaucratic monster, where the primary object of the exercise will be to get "over the bar" and avoid the penalty.

Although not as sexy as a new 10-year plan or world class commissioning, perhaps faster progress might be made by concentrating directly at local level on the key to it all - the morale, motivation, competence and attitudes of the staff who deliver the service.

In particular, is it time to have a closer look at the contribution of the nursing workforce to patient safety and patient experience? The health secretary's announcement that metrics are to be devised to measure the standard of nursing care suggests there is national concern about this issue.

Quality nursing

However much NHS leaders may wax lyrical about the wonderful job nurses do, this initiative is borne out of a concern that it is not universally as wonderful as it used to be. The case needs cold hard analysis rather than a rush to introduce a new national bean counting process to assess nursing quality.

The quality of nursing care is still the defining element of their experience for most hospital patients and one wonders if boards have paid enough attention to this vital workforce in the recent past.

Developing the nursing workforce has largely been left to the profession, and while there is no doubt that specialist nurses, advanced nurse practitioners and nurse consultants have delivered enormous improvements in providing support to specific patient groups, there is a feeling that the development of specialist nurses has resulted in ward-based nursing (and community equivalents) becoming something of a poor relation in the profession.

Managers may also have paid less attention to the quality of nursing care in the last decade because in their heart of hearts they have known that the scale and pace of productivity improvements and delivery of tough access targets were not compatible with an entirely honest discussion with nursing colleagues about guaranteeing the quality of the patient experience.

Board involvement

Whatever the underlying causes of poor patient experience, we are where we are and there is at least recognition across the service that the patient experience needs to be improved and to do so will require all professions to raise their game.

Ultimately, ensuring patients are treated safely and kindly on a consistent basis defines the job of local trust boards, their senior managers and clinicians. The annual staff survey is as good as anything available to boards for describing the current health of their relationship with their staff.

To move things forward from this starting point, there has to be a completely open and honest discussion about what is good and what is bad in the organisation and a collective meeting of minds between boards and their workforce about what each wants from the other.

As part of this, there needs to be willingness on the part of boards to be more honest about the realistic limits of productivity and to embrace the compelling argument for more investment in individual staff development, appraisal and welfare. On the other hand, staff must recognise that productivity and service quality are not mutually exclusive goals and that they should actively support and campaign for a zero tolerance approach to unacceptable behaviour towards patients or avoidable lapses in patient care.

Commitment to excellence

Some NHS staff will respond to the "market threat" as the reason for improving patient experience. Others (probably the majority at present) will respond better to a shared organisational passion for service excellence - where staff can see that the board's commitment to an effective, safe and compassionate service is not just a proclamation but is reflected in its business plan and its priorities for resource allocation.

This is not rocket science, it doesn't need national initiatives, but it is hard - boards and managers need to create time and space on their agendas to give the issue of improving patient experience the top priority it deserves.

The most difficult part will be the bargain to be struck in each organisation on the fairest way to reconcile the imperative to improve productivity, balance the books and hit targets with the intuitive belief of staff that the faster they have to run the harder it is for them to pay attention to the individual needs of their patients.