Background
In July 2007 the Labour government asked Lord Ara Darzi, the then junior health minister and an eminent surgeon, to conduct a ‘next stage review’ of the NHS in England. The review was, said the then health secretary Alan Johnson, a ‘once in a generation opportunity to ensure that a properly resourced NHS is clinically led, patient-centred and locally accountable’.
The initiative came seven years after the launch of the NHS Plan, which focused largely on increasing capacity in the health service and driving down waiting times. Those centrally directed targets have been largely achieved, in the previous government’s view. The new priorities had to be improving the quality of care and ensuring better outcomes.
The key challenges Lord Darzi was asked to address were:
- ensuring clinical decision-making was at the heart of the reform process
- improving the quality of services and ensuring they were more joined up
- making care more accessible and better integrated across primary and secondary care
- basing services around patient control, choice and local accountability and reducing central direction.
Although the new brief echoed some of the main themes of the 2006 White Paper Our Health, Our Care, Our Say – including personalisation, patient choice and the shift of services to the community – it marked a deliberate change of direction from most NHS reforms of the previous decade which had focused on outputs and were largely driven by top-down targets and, more recently, by the introduction of competition between providers. The focus of Darzi’s review was to be on quality and this was to be locally directed and staff led. One reason for this new approach was the growing feeling that although large amounts of extra cash had been pumped into the NHS over the previous seven years, the evidence for improved outcomes was still limited.
Lord Darzi had just produced his 10-year plan for the reorganisation of the NHS in London when he took up his new task. The London plan proposed the creation of larger specialist centres for the treatment of conditions such as stroke and heart attacks combined with a network of 150 GP-led health centres providing some of the services traditionally offered by GPs and district general hospitals. Darzi suggested that half the work done by district general hospitals could be devolved to a more local level.
His national review was based on a series of local, regional and national working groups. All nine strategic health authorities (SHAs) outside London were tasked with producing their own ‘visions’ of high-quality care in their region. These in turn were based on the findings of 74 local clinical working groups, consisting of local NHS staff and stakeholders, which focused on eight topics:
- maternity and the newborn
- staying healthy
- children’s health
- planned care
- mental health
- long-term conditions
- acute care
- end-of-life care.
In addition, five national groups examined primary and community care, quality improvement, innovation, the workforce and leadership. The Department of Health was responsible for reporting on systems and incentives, informatics and the NHS Constitution.
Lord Darzi produced an interim report in October 2007, which included recommendations to introduce MRSA screening for planned hospital admissions in 2008 and emergency admissions by 2010 as well as setting up 100 new GP practices in the most deprived primary care trust areas.
The most controversial of Lord Darzi's recommendations, also outlined in the interim report, was one to establish more than 150 new ‘health centres' around the country, which would provide an extended range of services and be open from 8am to 8pm seven days a week. The BMA presented a petition signed by more than 1 million members of the public protesting at the scheme which, it claimed, could spell the demise of the traditional general practice.
The strategic health authorities’ clinical pathway reports emerged in May and June 2008 and were followed on 30 June 2008 by Lord Darzi’s High Quality Care for All: Next Stage Review Final Report, which was accompanied by the draft NHS Constitution. Additional reports on community and primary services and the NHS workforce were published at much the same time.
