Darzi review must avoid national blueprint to enable best local solutions

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The case for change in the health service is irrefutable, argues The King's Fund chief executive Niall Dickson, but strong managerial and clinical leadership, astute financial planning and significant changes in working practices will be needed.

There is nothing quite like the politician's ability to raise expectations: when announcing Lord Darzi's review of the health service, the health secretary described it as a 'once in a generation opportunity'. So no pressure there then.

But today's plans are so often tomorrow's forgotten dreams. Interestingly, in a thorough, thoughtful and interesting speech a couple of weeks ago the Prime Minister did not once mention either the NHS Plan or the NHS Improvement Plan, which were supposed to be the guiding strategic documents for the first decade of this new millennium.

To be fair, the title 'NHS Next Stage Review' does at least imply there has been an earlier stage, but there are two obvious dangers in what is now being attempted.

First, the government had already embarked on a series of radical changes to the way health care was delivered in this country - it did not sell them well and it is still too early to reach any definitive view about their success.

Second, the sheer scope of the review and its extraordinarily tight timetable must be a cause for concern. Everyone understands the strictures of the political cycle but the process here is demanding and the ambition great. The review is expected to produce the right answer for: the reconfiguration of services, the quality and safety of care, the constitutional and accountability arrangements for NHS services, the right combination of incentives, the future of health care leadership, the right pathways of care, and the future shape of GP and community services.

Of course there is no 'right answer' in many of these areas, and whatever the optimum answer is now, it is quite likely to be different in a couple of years' time. Perhaps what is needed here is a little humility and a recognition that change is not a one-off event, but an endless process that should be guided with an occasional look at where we have come from, where we are and where we want to go.

Lord Darzi himself has acknowledged this by making it clear that his earlier report on London's NHS should be seen not as a plan or a blueprint but rather as a stimulus and a pointer to the direction of travel. Seeing it in these terms would help to create a health system that truly puts patients first, offering services that are responsive to local circumstances.

The process must be driven by the need to improve outcomes and that will be achieved only if those who deliver care are involved and 'buy into' the process and its results. That will not be easy, partly because so many clinical staff are disillusioned and partly because they will not all agree on the way forward.

The managerial challenge is therefore formidable. It will require astute financial planning, strong clinical and managerial leadership, and a commitment to making significant changes in working practices.

If the Darzi Review is about enabling change then it has real potential. This is the time to begin to thrash out models and ideas, so that commissioners, who must drive this process, together with managers and clinicians can begin to develop local solutions.

The King's Fund will be playing its part. We have undertaken an analysis of some key aspects of the London review to feed into their consultation and we are completing a review of the polyclinic model of out-of-hospital care. At the same time, Alasdair Liddell, one of our senior associates, will lead an expert working group on incentives within the health system that will draw on the experiences of those working in the NHS.

We have just published a discussion paper - Governing the NHS: Alternatives to an independent board - and will shortly add to that with an analysis of local accountability.

It is easy to be negative, but the case for change in the health service is irrefutable. We might not have chosen this way to bring it about, but if Lord Darzi and the government are brave enough to develop the incentives so that clinicians, commissioners and managers take hold of this agenda, and develop meaningful solutions with their local communities, maybe the 'once in a generation' review will be just that.