The King's Fund response to Lord Darzi's NHS Next Stage Review

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In response to the publication of Lord Darzi's NHS Next Stage Review today, The King's Fund said that while it would always be difficult to live up to its 'once in a generation' billing, in general, the report was good news for patients. The big test will be making this a reality.

Niall Dickson, The King's Fund's Chief Executive, said:

'The good news is that there is no top-down re-organisation or any dramatic changes in direction. Instead, the report is a sensible set of measures to improve quality and equity, and a clear signal that responsibility for shaping and leading health services lies with staff at local level.

'For the first time in a systematic way hospitals and GPs will have to account for the outcomes from the care they provide. This will be a new era in which patients will be able to check on the quality of the services they are being offered from infection levels to success rates following operations. All this should help us all make more informed choices and put pressure on those providing the care to do better.

'To make this happen we need a decentralised health service, with less central control, leaving local organisations responsible for how they deliver care but accountable for its quality. While services provided by the NHS are far from uniform, increasingly devolved decision-making could result in significant regional variations in the care provided to patients.

'So far there are two significant omissions – there are no estimates of how much all this will cost and no indication of just how different the government expects the quality of health services to be in five or ten years time. Some of the answers lie in the regional plans but an overall view of how far and how fast the government expects the NHS to change would be helpful.'

On the new NHS constitution

Niall Dickson said:

'Today's announcement of a constitution for the NHS could deliver real benefits to patients – it provides a positive statement of patients' rights and how they can exercise them, as well as what services the public can expect to receive. The constitution enshrines the right of patients to choose where and how they are treated and will help people take greater control of their own health care. For choice not to be meaningless patients will need robust information to ensure they can make informed choices.

'The NHS constitution also reinforces the deal between taxpayers, patients and the state. It underlines the reality that the letters NHS no longer describe a state-run business – instead the NHS is a commissioner of comprehensive health care, free at the point of need. This means NHS care can be provided by all sorts of organisations public, private or from the voluntary sector.'

On local accountability

Niall Dickson added: 'It is critical to ensure that devolving decisions to local organisations does not lead to devolved power without devolved accountability. There’s also a need to be clear about what kind of accountability is being promised.  PCTs need to take more account of local views and give a clearer account of their decision-making to the people they serve. We need to build on the existing mechanisms the NHS already has in place, such as strengthening the role of Overview and Scrutiny Committees.'

On regional SHA plans

Niall Dickson continued: 'There have always been regional variations but the difference here is that they are more explicit. There is an inherent tension in the government's desire to establish national guarantees and standards in order to get rid of the 'postcode lottery' while at the same time SHA plans and devolution to PCTs mean that some regional variation is inevitable. The issue for the future will be how to balance what is acceptable variation to meet local needs and what is unacceptable variation in terms of quality of care.'

On individual health budgets

Dr Anna Dixon, The King's Fund's Director of Policy, said: 'We need to look carefully at the implications of extending personalised budgets into the health service. Although direct payments are being used in social care, their effective use in health care is more of a challenge. Challenges include getting the initial payment level right and determining who would pay for care should the budget be exhausted. There is also the danger that converting NHS services into cash could allow the better off to enhance their allowance thereby creating a two-tier service, which undermines the founding principles of the NHS.'

On speeding up the NICE approval process

Prof John Appleby, The King's Fund's Chief Economist, said: 'NICE grapples with the difficult decisions about what the NHS should fund and is recognised world-wide as a real success for its cost effectiveness evaluations. Although its work is both rigorous and transparent there have been concerns that its decisions take too long. Moves to speed it up are good news for patients, however, NICE needs to be careful not to sacrifice rigor for speed.

'While today's announcement should go some way to reducing the postcode lottery in access to drugs, the main area of dispute occurs when some PCTs are reluctant to fund drugs that have a licence but which are yet to be evaluated by NICE. Dealing with this source of variation is more difficult and may well require central guidance to ensure consistency across the NHS as well as the proposal that PCTs need to explain their local judgements regarding funding of drugs yet to be evaluated by NICE.

'However, an even more important source of variation in access to care arises from differences in the clinical decisions of doctors about who to treat, when and how. Rates of the most common operation in the NHS – cataracts – can vary more than four-fold across England, for example. The Department of Health and the NHS need to put much more effort into understanding why such variations exist and what needs to be done to ensure more equitable access.'

On changes to primary care

Dr Nick Goodwin, The King's Fund Senior Fellow, said: 'The call for comprehensive well-being and prevention services with local authorities suggest a direction of travel in primary care providers towards managing health rather than treating illness. This will require significant changes in the way primary care is managed and organised with greater multi-disciplinary working and tailored support for patients in a way that has not previously been seen.'

On public health

Tammy Boyce, The King's Fund Research Fellow in Public Health, said: 'We welcome the review's commitment to a new emphasis on preventive services. If we do not make significant strides on tackling unhealthy lifestyles, especially with regard to obesity or alcohol, then we will have to spend substantially more on the NHS than would otherwise be the case – so much so that it could threaten the long-term viability of the service.

'We have seen many well meaning initiatives before – it remains to be seen whether the Coalition for Better Health will have the authority needed to make a difference and whether there will be a firm commitment to increase spending on public health. The health service cannot solve all the nation's social problems but it can do more in the key areas identified by the report.'

On leadership

Karen Lynas, The King's Fund Director of Leadership, said: 'David Nicholson has been consistent in his interest in securing high-quality leadership for the NHS. It is reassuring that he is making a personal commitment to maintain this as a priority by creating an NHS leadership council to identify and support the top 250 leaders. It is also promising that there is an assurance of continued investment in leadership development, with a particular focus on clinical leadership. However, how this investment is realised, and how the balance between national and local activity and control is secured, is as important in leadership development as it is elsewhere in this report.

'The welcome move to realising local control and autonomy over the development of services, and the move away from top down imposed targets could well be seen as a model for leadership development. Many of the SHAs have now established, or are on their way to establishing, creative and intelligent approaches to locally developing talent.'

Notes to editors

  1. For further information or interviews please contact The King’s Fund media and public relations office on 020 7307 2585, 020 7307 2632 or 020 7307 2581. An ISDN line is available for interviews on 020 7637 0185

  2. The King’s Fund is an independent charitable foundation working for better health, especially in London. We carry out research, policy analysis and development activities, working on our own, in partnerships, and through funding. We are a major resource to people working in health and social care, offering leadership development programmes; seminars and workshops; publications: information and library services; and conference and meeting facilities.