The Department of Health has published an ambitious framework for improving the quality of NHS care but its architect Lord Darzi has warned it is likely to get off to a slow start.

All NHS organisations were this week sent details of how they should approach the commitments made in the health minister's next stage review, which makes improving quality the centrepiece of the next decade of the NHS.

Each tier of the NHS - from local clinical teams to boards, strategic health authorities and the National Quality Board - is being asked to select the indicators it wants to use to measure, compare and improve the quality of services.

In an interview with HSJ, Lord Darzi stressed that local organisations would be free to choose which indicators they wanted to use (see below). He would not be drawn on how many he expected to see in trusts' quality accounts - which they will be legally required to publish from 2010, giving them the same priority as financial accounts.

Crawling before walking

But he admitted the process would take time. "We are going to start crawling and then we are going to start walking and then we are going to start running," he said. "This will take a bit of time."

SHAs must report to the DH their progress on choosing indicators and developing quality accounts by the end of January. Lord Darzi said it was a "dynamic process" and, by April 2009, all trusts would be expected to do was begin to report quality indicators. Details published this week indicate that the NHS will only "potentially" pilot quality accounts in 2009. Trusts were expecting to have to begin preparing data from April 2009 and publish the first accounts by June 2010.

NHS Confederation policy director Nigel Edwards said the plans would be broadly welcomed by managers, though it was important measures were not seen as centrally defined targets. But he said: "There is a danger of getting hung up on not having too many national measures. What you report is a different debate from what you collect."

The Advancing Quality performance scheme running in the North West was cited by the DH as an example other regions may wish to follow.

NHS North West chief executive Mike Farrar told HSJ: "What we are trying to do is balance getting everybody to develop their own ideas, and overlay that with something that allows people to compare."

Royal Salford foundation trust chief executive David Dalton said many trust boards would need to learn the different approach to performance management required to engage staff in improving quality.

"Without it, there will be no real ownership and there will be dis- satisfaction when existing approaches to performance management are not seen to bring results."

The document fails to identify a clear role for commissioners. Managers said primary care trusts should fight for a leading role. Central Lancashire PCT chief executive Joe Rafferty, previously NHS North West director of commissioning, said: "It is easy for it to seem like a provider-centric activity. We need to commission for quality and be involved for example through contracting."

Lord Darzi told HSJ he welcomed commissioners' views, but did not expect them to feed into the selection of indicators. "We are providing the richest bit of information any commissioner will ever dream of, and the commissioners will turn around and say: 'Fantastic, this is the service that is worth providing, that is what I'm going to buy.'"


Strategic health authorities

  • Measure improvement on commitments made in regional Darzi visions

  • Account for quality, probably using next stage review eight pathways of care, potentially publishing results

  • Engage organisations to identify indicators they are using

  • Establish new quality observatories or develop from existing arrangements

  • Support commissioners in contracting for quality improvement

  • Provide support and co-ordination to providers


  • Prepare to publish quality accounts

  • Give feedback on initial 400 indicators

  • Provide details of indicators currently used

  • Managers to provide resources, leadership and culture to support teams to improve quality

  • Set priorities for quality improvement and how to measure them

  • Managers trained to understand and respond to data on quality

  • Support clinical teams to engage in the measurement and reporting process


  • Take responsibility for quality and specify measures to be used across pathways and systems

  • Incorporate quality checks in contracts and linking to payment with commissioning for quality and innovation scheme

  • Co-develop regional quality measurement and monitoring systems

  • Work in groups to set priorities for providers to measure


Health minister Lord Darzi put improving the quality of services at the heart of his next stage review. Four months later, the Department of Health has outlined the process for measuring quality and reporting on it.

Talking to HSJ this week, Lord Darzi stresses that different tiers of the NHS - from clinical teams to boards and strategic health authorities to the National Quality Board - will choose different measures of quality from a "toolkit" of indicators.

"That's the important thing," he says, "different levels for different purposes."

As he talks, he draws a diagram in the shape of a pyramid, despite the fact that he says be does not "believe in a hierarchical structure".

The only element to be set in stone will be the principle that tools must measure safety, effectiveness and patient experience: "These are not negotiable."

He will not specify how many measures it would be appropriate to choose.

"It's the clinical teams trying to decide what improves their service and they have to have freedom in deciding that... it's not for us to decide what they wish to measure," he insists.

He stresses the importance of clinical - and managerial - engagement and seems to have no concerns about the timescales. "This is a dynamic process," he says. "It is a rebuilding of the whole of the engine from the bottom up."

Strategic health authorities have a major role, he says.

"SHAs have a tremendous amount of leadership in getting this group excited and engaged in providing and really getting on and bringing this ethos of service improvement."

Despite the use of the word in the Department of Health framework, the quality accounts are not pilots, they are here to stay, he says. "It's for them to test what they are doing for a year before it actually becomes part of legislation in 2010."


3 July 2008 Improved service quality at heart of Darzi's next stage review

18 November 2008 DH publishes indicators survey seeking health professionals' views on existing indicators and others they wish to use

12 December 2008 Survey closes

January 2009 NHS Reform Bill, setting out legislative basis for quality accounts, expected to be introduced

30 January 2009 SHAs to report to DH on local measures for use in quality accounts; proposed regional measures; ideas for national indicators and how to improve skills and capacity

April 2009 Trusts start collecting data for "potential" quality accounts pilots

July 2009 NHS Reform Bill expected to receive Royal Assent

By end 2009 DH will have laid regulations and issued guidance on which providers will be required to produce quality accounts, their format and the publication timetable

April 2010 First quality accounts to be published


Cynthia Bower, Care Quality Commission chief executive: "We are working with the Department of Health to ensure our regulatory work aligns with their work on quality. We are keen to see patients, carers and the public involved in identifying how the quality of care should be measured. Everyone acknowledges a collaborative effort is needed to improve the quality of care for the people who use services."

Rashmi Shukla, NHS North West director of public health and medical director: "We do need comparative data at lots of different levels. It is important to be clear at the outset what the purpose of each indicator and comparator is. Also we are keen that equity is there as a separate domain of measuring quality."

Nigel Edwards, NHS Confederation policy director: "There will have to be enough data to do the standardisation, so there is no escape from the data collection. There are costs to introducing this and we need to be careful we are getting the benefits. There is a tendency to put things [indicators] in without taking things out."

David Dalton, Royal Salford foundation trust chief executive: "It is important to be very clear about what we are going to be measured on, but understanding that we want to select other measures ourselves and go about making those improvements."

Julie Garbutt, Norfolk PCT chief executive: "This supports the integral work for PCTs, ensuring clinical leadership and quality of services are at the heart of commissioning, and provides a strong framework for monitoring."

Watch a video on the quality framework