Devolved power flows through Darzi's vision

The publication of the next stage review was the culmination of a year's work between the health service and the Department of Health to set out a vision and strategy for the NHS over the next 10 years. The reception from our patients, public, staff and stakeholders has been overwhelmingly positive.

This positive reaction was not achieved by accident. From the outset, health minister Lord Darzi made clear he wanted his report to be an "enabling" document, because he as a clinician he knew that real change can only be delivered from the bottom up. Two key strategic decisions were therefore made.

First, the work we had already begun on what matters most to our patients, public and staff provided an important foundation for the next stage review.

Second, Lord Darzi asked each strategic health authority to come up with its own regional vision for the NHS, by engaging thousands of staff and stakeholders. These 10 visions directly shaped the final review, which outlined the enablers and support required nationally to deliver what clinicians, patients and public told us they wanted locally.

Now our attention must turn to how we create the right conditions to support successful implementation of the ambitions set out in the 10 regional vision documents and the review.

Meeting expectations

I have given much thought to how we best achieve this, and my expectations of the leadership of the NHS at local, regional and national levels. I am clear about three things: first, to successfully implement the vision in the next stage review - to put quality at the heart of all we do - requires a degree of ambition and change that has never been attempted anywhere before.

Second, it follows that our traditional methods of implementation will simply not be sufficient to deliver the ambitions we have set for ourselves.

Finally, the success of the review was largely due to the bottom-up process we adopted during the development of the 10 visions and the national enabling document; we need to build on and strengthen these principles.

Following discussions with Lord Darzi, health secretary Alan Johnson and people from the service, we are agreed that the implementation process must reflect the principles we established during the policy development phase, namely:

• co-production: how we implement the next stage review must be discussed and decided in partnership with the NHS, local authorities and key stakeholders;

• subsidiarity: where necessary, the centre will play an enabling role, but where possible, details will be determined locally;

• clinical ownership and leadership: our staff who will be required to make the necessary changes must continue to be active participants and leaders;

• system alignment: the review and the constitution clarified that the NHS is a system, not an organisation, and the wider system therefore needs to be aligned around the same goal so that we use our combined leverage to drive up quality across this system.

Three strands to implementation

Over the coming months there will be much activity both national and local to develop implementation plans. I think of them at three levels, but am clear that all need to reflect the principles outlined above.

First, out in the service there is a lot of work in train to implement the regional visions. Primary care trusts will be developing their commissioning strategies and operational plans to reflect both their regional vision and the review document. I expect the NHS at both SHA and PCT level to conduct this process in a way that reflects the principles set out above, continuing to engage with their patients, public, staff and local authority partners as they did so successfully during the development phase.

It is also important that we demonstrate our commitment to diversity and the NHS values in the way we develop and implement our plans.

Second, in the DH we must ensure clear plans and accountability arrangements are in place to deliver the review proposals. We will do this in partnership with the service and stakeholders, in line with the principles I set out above.

To this end Lord Darzi and I will be travelling around the country from 8 September to 8 October, to listen to the views of the service and key stakeholders about how we implement the review. At the same time more detailed work will be carried out in the executive groups of the NHS management board, pulling in a range of people from the service and stakeholder organisations to work in partnership with the DH as the policy development goes on to the next phase. These conversations will directly feed into the development of the operating framework, which will, in effect, set out the implementation plan.

Third, while the first two strands of implementation are necessary, they are not in themselves sufficient. To successfully align the entire system so that quality is truly our organising principle, with a greater focus on prevention, will require a deep cultural change as we move from one system to another. The review sets no new national targets, but requires radical changes in behaviour at individual, team, organisation and system level.

Uncharted territory

Although the NHS management board had begun work with the wider NHS leadership community before the review process started, to look at this area of managing the system and leading change, I genuinely think this is exciting but uncharted territory for something as large and complex as the NHS. We will build on this work over the next few months with national and international experts, culminating in a large event in the autumn for the wider leadership community in health and social care.

In the past the NHS has tended to focus its efforts on the management of today rather than development for tomorrow. It is clear this is no longer a successful or sustainable model of leadership. The NHS has proved it can deliver the priorities of the government. The challenge for management now is to develop our people and systems to be able to deliver the services and outcomes our own communities want - not just for today but for tomorrow.

I do not underestimate the challenges we have set ourselves - both in what we need to do and how we aspire to do it. Our behaviours will not always reflect the ambitions we have set ourselves. But that is why it is vital that people within the system understand what we are trying to do and how we intend to do it.

Next steps

Lord Darzi, the NHS leadership team and I will devote much time over the next few months to conversations with people that build and strengthen the movement and shared purpose the review so successfully produced. I expect regional and local leaders to do no less. I expect every NHS organisation to be actively communicating the review vision and having real discussions with staff about how we make it real.

I know many organisations are already doing this. In addition to public consultation events in every PCT area, I want all staff to have the opportunity to contribute to the consultation on the NHS constitution - a process being very ably led by the SHA chairs. The review was not just a report but the beginning of a real movement, and all our activities need to reflect and build on that.

Since 2000 we have been building capacity in the NHS, with substantial extra investment in staffing, infrastructure and major new programmes of work. We have the right incentives and systems in place through strengthened commissioning arrangements, choice and foundation trusts.

The next stage review sets out a clear vision for the NHS going forward, one where quality truly is the organising principle. We now have clarity and consistency of purpose across the NHS, based on real evidence of what matters to our patients, public and staff. This is the foundation for bold and locally led change that will deliver real improvements for all.

HSJ's NHS Change Management conference on 22 October will help you guide your staff through the next raft of reform, www.hsj-change.com