Informing the review
The
review has been informed by consultation exercises with patients, staff and the
public and by the work of a series of local, regional and national working
groups. The review has held consultation events in each of the nine strategic health
authorities (SHAs) outside London
and an international summit, which included presentations from other countries;
it also provided an interactive website – www.ournhs.nhs.uk
– that has encouraged individuals and organisations to give their views.
Local and
Regional Work
Eight
‘clinical pathway groups’ comprising local NHS staff and stakeholders were set
up in each of the nine SHAs outside London in October 2007 and asked to develop
a plan for ‘world-class quality care’ in their area. The groups were organised
around eight clinical areas: maternity and newborn care; children’s health;
planned care; mental health; staying healthy; long-term conditions; acute care;
and end-of-life care.
Drawing
on the work of these groups, each of the nine SHAs has developed a document
outlining their ‘vision’ for health care in their respective regions for the
coming decade. These documents are being published in May and June 2008, in
advance of Lord Darzi’s final national report.
National Work
Five
groups were charged with identifying the changes required at a national level
to enable the proposed local and regional changes to be implemented. These
groups have focused on: primary and community care; quality improvement;
innovation; workforce; and leadership.
Additional
work was being undertaken by the Department of Health on: systems and
incentives; informatics; and an NHS constitution.
Early insight
into Lord Darzi’s plans
An
interim report was published in October 2007 – in this report, Lord Darzi made
clear that the current set of NHS reforms, such as patient choice, Payment by
Results and reforms to regulation, must be allowed to continue. The report’s
headline recommendations focused on patient access to family doctor services
and increasing the capacity of primary care services in under-doctored areas.
Lord
Darzi recommended 100 new GP practices in the 25 per cent of primary care
trusts (PCTs) with the greatest need He
also recommended that 150 new health
centres should be built throughout the country – these would provide a range of
services, such as diagnostic tests, minor surgery, and 8am–8pm, 7 days a week.
Since the interim report was published, the government has introduced a new
financial incentive (recycling existing incentive monies for GPs) for practices
which provide on average three hours of additional appointment time in evenings
or at weekends.
The
interim report also recommended the introduction of MRSA screening for all
planned hospital admissions in 2008 and all emergency admissions by 2010; and
the establishment of a Health Innovation Council charged with being ‘the
guardians of innovation, from discovery to adoption’.
What will the final national report recommend?
The
final report has been described as a ‘framing’ or ‘enabling’ document, which
will identify the national policy changes required to help managers take
forward changes to local health services. The national review team, in an effort
to allay public anxieties, has recently published a set of rules to govern changes
to local services – they must be to the benefit of patients; clinically driven
and locally led; involve consultation with patients and the public; and
existing services should not be allowed to close before new services are in
place and delivering benefits.
The
following sections outline the key issues each of the national working groups are
likely to be grappling with.
Primary and Community Care
This team has a particularly
wide remit, and recommendations relating to primary care are likely to play a
significant part in Lord Darzi’s final review. It has been asked to consider:
‘the models of care being
developed locally, and [to] develop a vision of world-class primary and
community care services, capable of tackling existing challenges of access and
inequality, and focusing ever more strongly on promoting health, encouraging
self-care, predicting and preventing ill-health and managing long-term
conditions’.
Integrating Care
A major challenge for primary
care is how to integrate services around the needs of the patient. This means improving
not only accessibility, but also communication between different parts of the
health service. This is especially important in the management of long-term
conditions, where patients may use services frequently and where a failure to
identify and treat a minor problem can result in an emergency admission to
hospital, which is bad for patients and costly for the health service.
The focus is now on
helping different parts of the health system to work better together. This
could be done through developing clinical networks or establishing clearer
pathways, both of which could be supported through the development of polyclinics.
The term ‘polyclinic’ has been used to describe a variety of different
approaches from very large super surgeries, which involve closing current GP
practices and moving their services into the new unit, to the so-called hub and
spoke model, under which clusters of GP practices create formal links with one
another and draw on a common set of community-based diagnostic and specialist
resources. Polyclinics could bring together family doctors and specialists
alongside a range of other services, such as diagnostic testing and minor
surgery. They could also bring more outpatient work out of hospitals and
provide other ‘one-stop shop’ facilities such as blood tests and x-rays.
Lord Darzi’s review of London’s NHS recommended
that polyclinics be introduced across the capital. He described them as ‘new
facilities that would offer a far greater range of services than currently
offered in GP practices, while being more accessible and less medicalised than
hospitals’. Lord Darzi’s proposals for London,
which have now been consulted on, identify the polyclinic as the place where most
routine health care needs are met in the capital.
Although polyclinics are
being considered as part of the national review, Lord Darzi has distanced himself
from the models of large polyclinics that locate GP and other services in a
single, centralised building and has expressed an interest in the hub-and-spoke
model.
The King’s Fund supports
the hub-and-spoke model over those which centralise GP care, but urges
commissioners to focus on developing new care pathways, technologies and better
joint working across teams and professions. Developing new facilities may be part of the strategy, but buildings should be
a means to an end, not an end in themselves (Imison et al 2008).
Choice
Extending patient choice
in primary care is also in the review team’s remit, specifically identifying
the changes required to make it easier for patients to change GP practice and
to be able to register near their workplace. In addition to making services
more convenient to patients, this is intended to introduce competitive pressure
on GPs (similar to that introduced in the hospital sector) to respond to
patients’ preferences.
In theory patients can
already choose their GP practice, but in practice lists may be closed (or ‘open
but full’) or new registrations may be restricted to people living within
certain geographic areas. In addition, some GP funding arrangements act as
disincentives for practices to take on new patients. For example, the Minimum
Practice Income Guarantee (MPIG) – introduced with the new GP contract in 2004
to safeguard practices against any loss of income resulting from the move to a
new funding formula – protects practices’ existing income levels. Also, under
the General Medical Services contract if a patient moves practices, the new
practice receives less than 70 per cent of the funding for that patient and
additional ‘premises’ funding stays with the original practice. The government
intends to review these arrangements.
New providers
The introduction of
Alternative Provider Medical Contracts (APMS) in 2004 opened up the provision
of primary care services to commercial and voluntary sector providers without
NHS links, but use of these contracts has been slow (Walsh et al 2007). The review team will need to identify what can be
changed to encourage providers and commissioners to use existing routes more
effectively, or to consider whether new contractual mechanisms are required. Any
new organisations must be subject to the same regulatory standards as
traditional providers.
Encouraging new providers
and patient choice could conflict with maintaining continuity of care. As the
Royal College of General Practitioners has pointed out, increasing flexibility
in access to primary care may be desirable to young and relatively healthy
service users who prioritise convenience, but those with long-term conditions
and co-morbidities are more likely to benefit from a consistent relationship
with a GP.
Quality
Improvement
This
team, led by the Chief Medical Officer, has been tasked with developing a
strategy for ‘speeding and embedding quality improvement across the health and
social care delivery system’, to include drawing on international evidence of
best practice in ‘standard setting, data collection in clinical practice,
inspection and review of health care services, and supporting quality
improvements’.
The
Health and Social Care Bill currently in Parliament deals specifically with the
reform of regulation in health and social care, including the establishment of
a new Care Quality Commission (House of Commons Bill 2007-08). The regulation
of health professionals was the subject of a recent White Paper, and implementation
of its recommendations is being considered separately. The focus of the review
team is likely to be the day-to-day delivery of care in hospitals and
elsewhere.
Despite
concerns about variability in the quality of clinical care in different parts
of the health service and occasional scandals revealing poor practice, a lack
of systematic data on care processes and outcomes for patients makes it
impossible to benchmark standards of clinical practice. Enabling data on
clinical processes and outcomes to be comparable across different units and
different clinicians also requires the information to be risk-adjusted to take
into account the differences in the conditions of patients needing care.
There
have been recent developments on this. The new ‘Standard NHS Contract for Acute
Services’ introduced this year requires all hospitals providing services for
NHS patients to publish patient-reported outcome measures for a limited number
of procedures from April 2009. Together
with the Society for Cardiothoracic Surgery in Great
Britain and Ireland,
the Healthcare Commission has also developed a database and accompanying
website showing survival rates for heart surgery at different surgical units
across the United Kingdom
(Healthcare Commission 2008).
This
team is also likely to draw on international evidence to make recommendations
in relation to whether certain types of specialist services, such as trauma and
stroke care, ought to be centralised into specialist centres. Research to date
has found that for some types of treatments, higher volumes of patient throughput
are required to maintain institutional and individual competence and are
associated with improved health outcomes for patients.
One
option apparently being considered in relation to primary care (Lakhani 2008)
is to recommend some form of national accreditation scheme which would grade
services or institutions giving them the equivalent of a kite mark of quality –
the accreditation standards would be above the basic level required by the new
regulator the Care Quality Commission.
The
government has also indicated that it plans to make payments to NHS hospitals
adjustable according to patient satisfaction and health outcomes (see Systems and Incentives).
Innovation
This
group must develop a strategy for ‘speeding up and embedding innovation’ across
health and social care services in relation to medical devices,
pharmaceuticals, clinical practice and delivery models and management. The term
‘technologies’ is used to refer to these areas collectively.
The
United Kingdom
is traditionally slow to adopt advances in medical technologies. While the
government has not introduced targets or wide-ranging initiatives in this area,
they have established a number of new organisations and initiatives intended to
speed up the process of adopting and implementing innovative technologies.
Evidence
on the value of new technologies is generally poor, making it very difficult to
estimate the scale of potential benefits and the costs of achieving them. While
some technologies may reduce unit costs, it has been predicted that as a whole
new technologies will put upwards pressure on health spending as they deliver
quality improvements (Wanless 2001).
In
contrast, improvements in service design and delivery may lower costs and
improve quality. There has been a sustained drive since 2000, first through the
Modernisation Agency and now its successor the NHS Institute for Innovation and
Improvement, to deliver services more effectively. This has achieved a number
of successes, such as reducing waiting times for diagnostics and for treatment.
But such improvements are not replicated quickly enough across the service as a
whole.
The
challenge for this part of the review will be in identifying novel solutions to
longstanding structural and cultural barriers to technological innovation of
all kinds in the service.
Workforce
This
team has been asked to develop a long-term strategy for workforce planning
which will ensure that education, training and planning processes produce a
workforce of the right size and structure, which is suitably skilled to deliver
a high-quality service. The terms of reference add that the workforce must also
be sufficiently flexible and sustainable to meet the changing needs of patients
and the service and that the future roles of clinicians and their career
pathways should be clearly described.
The
immediate concern for the team should be the lack of connection between
workforce planning and financial and service planning. For example, the policy
of shifting care out of hospitals into community settings will require
retraining and redeployment of existing staff; as yet no details have been
published on how this might be achieved. At both regional and national level,
the importance of workforce planning both in its own right and in relation to
service and financial planning must be better recognised through organisational
structures and skills development. Workforce planning is often demoted to a
secondary concern after service and finance strategies have been agreed.
The
team will also have to consider the longer term. As Sir John Tooke recommended
in his report of the Inquiry into Modernising Medical Careers, this requires
the development of ‘common and shared understanding(s)’ of professional roles
within health care teams (Tooke 2008) and how they will develop in future.
Education and training then ought to follow on from the establishment of these
roles, which Tooke recommended should be developed in consultation with all
major stakeholders and should take ‘due account of public expectations’.
Sir
John Tooke is now working with a range of organisations to define the role of
the doctor in the 21st century with a view to reaching consensus by the end of
this year.
A
major challenge will be to identify how education, training, career paths and
regulatory structures can be organised so that they can respond to evolving
service demands. A further challenge will be to work out how professional roles
and job definitions can be changed so as to make the workforce more productive.
The
team will also have to make clear the extent to which national workforce
planning has a future and how far planning should be devolved to a local level –
indications thus far are that Lord Darzi would prefer to see local solutions.
Leadership
Work on leadership is being supported by three
working groups. The first is examining ‘the leadership model’ and is tasked with
defining ‘what excellent leadership in the NHS looks like and what needs to be
done nationally to encourage the behaviours we are seeking.’ This will produce
specific recommendations in relation to appointment, assessment and promotion.
The second group is focusing on ‘getting the right people’, which includes
consideration of increasing diversity among NHS leaders, recruiting more women
and people from ethnic minorities. Finally, the ‘leadership development’ group
is examining how developing leadership skills can form a part of all
professional training in the NHS. These three streams are each being managed by
senior representatives from strategic health authorities who lead on workforce
planning.
One recurring tension in the development
of leadership strategies is whether the NHS should (in this context) be thought
of as a single business, like Tesco, or as an industry, in which a collection
of organisations are working for a common purpose within a regulatory
framework. The ‘single business’ model allows central mandates to be issued
about best practice and would permit ‘talent’ to be managed centrally and moved
around the system without the requirement for recruitment processes. The
industry model makes it more difficult for individual organisations to be
mandated to take actions and requires appointment processes to be followed when
individuals move roles or organisations. In grappling with this issue, the
group will need to define clearly national, regional and local responsibilities
in the development of leadership.
This group’s recommendations will almost
certainly emphasise the importance of ‘clinical leadership’. This presents an
opportunity to better unite clinicians and managers in the pursuit of national
policy objectives and to engage clinicians in considering the economic
implications of their actions. It also allows those with frontline knowledge to
feed back on whether policies are achieving (or are likely to achieve) their
objectives.
In the context of frequent structural
reorganisations and leadership investment programmes that have to date focused
on rectifying failure, a new leadership strategy for the service ought to focus
on valuing and positively investing in existing leaders, rather than solely on
bringing in new talent.
Additional areas
Systems and
Incentives
There is
no published information on the scope of the work the Department of Health is
undertaking here. It could include: reviewing whether existing systems of
financial incentives in primary care are helping or hindering the achievement
of policy objectives; considering how staff contracts could be used to
encourage greater productivity (Williams et
al 2006, Buchan et al 2007); exploring
what incentives could be used to encourage healthy behaviours (see King’s Fund 2008).
The
Prime Minister has announced that payment for NHS hospitals will be adjusted
according to patient satisfaction and health outcomes (Hansard 2008). This
could entail making a particular proportion of the national tariff payable only
on the achievement of particular quality standards.
The
King’s Fund has commissioned an expert working group to contribute to this
strand of Lord Darzi’s review. The resulting report will include
recommendations for the strengthening of PCT commissioning through the
appointment of independent clinical advisory panels to assist commissioners;
SHAs devising incentives to reward strong commissioning; and the development of
national quality indicators which PCTs can use in contracts with providers.
This report will be published in June 2008.
Informatics
NHS Chief Executive David Nicholson commissioned
a review of informatics to examine how the collection and sharing of
information in the NHS can be improved, minimising the burden of collection on
organisations while maximising the use of the information that is collected;
and how to align the aims of existing and future information projects with NHS
priorities. This will include reviewing the National Programme for IT and
better integrating decision-making on informatics in the Department of Health
with policy-making across other areas of health care.
By 2014 the National Programme for IT is intended
to deliver an integrated electronic patient records service; an electronic
prescribing system; a digital images communications and archiving system; an
electronic appointment booking system; an NHS email and directory system; new IT
systems for GPs to enable them to easily transfer records; and an IT
infrastructure to support all these systems.
All of these programmes have begun to be
implemented, though some are behind schedule. In addition to delays in
implementation, the programme has also been criticised for failing to
demonstrate that its investment represents value for money. The planned spend
on ICT in the NHS in 2006/7 was almost £3 billion (Wanless et al 2007).
Sir Bruce Keogh, formerly NHS Medical Director, has been appointed to the new
role of Chief Information Officer. Given Sir Bruce’s previous interest and
pivotal role in the development of a database of risk-adjusted heart surgery
outcomes (see Quality Improvement
section above), his appointment could signal a new focus in the Department of
Health’s informatics strategy on collecting and making available data on care
quality.
NHS Constitution
and Local Accountability
The
Prime Minister recently confirmed that the government intends to establish an
NHS ‘constitution’, which ‘sets out what patients can expect to get from the
health service, including entitlements to minimum standards of access, quality
and safety’. This will be a key issue in Lord Darzi’s review.
The
Department of Health has already developed a ‘statement of principles’ for the
NHS (Department of Health 2006a, Department of Health 2006b), to which the
Conservative Party has given its support. The model NHS contract for 2007/8
required organisations to ‘have regard for’ the statement of principles, though
it is not clear how this might be enforced.
A
constitution could set out minimum standards of service – for example, a
guaranteed maximum waiting time or the promise of a choice of hospital.
However, these could change quite often, making it inappropriate to enshrine
them in primary legislation. And there is a risk that a legally enforceable set
of rights and responsibilities may lead to disputes over entitlements being
resolved in the courts rather than in PCTs or the National Institute for Health
and Clinical Excellence. On the other hand,
a constitution must be more than a set of aspirations.
The King’s Fund has
argued (Dixon et al 2008) that a
constitution could be useful in setting out the roles and relationships of key
players in the health system, including the Department of Health, making it
clear how the NHS is governed and who is responsible for which types of
decision. However, the Department of Health will have to balance this against
the dangers of issuing hollow rhetoric and over-specifying things which will
either lock-in the status quo or open the NHS to legal challenges.
The constitution might
also specify mechanisms for local accountability. The Prime Minister has
recently said that the government plans to strengthen public involvement in
commissioning arrangements. PCTs already have a legal duty to consult the
public and are subject to scrutiny by Local Involvement Networks (LINKS) and
local authority overview and scrutiny committees. However, some have argued for
strengthening the role of the public by allowing directly elected PCT boards or
instituting membership arrangements similar to those of foundation trusts.
Stronger local democratic influence over PCT commissioning could be expensive
to set up and could lead to a conflict between central government policy and
locally driven decisions.
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