Making Darzi's vision a reality

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The NHS Next Stage Review outlines a sensible set of measures to transform patient care, but The King's Fund's chief executive Niall Dickson argues that real cultural change will be needed in the health service if the vision is to be translated into reality.

The history of NHS reform is littered with good intentions – there have been countless attempts to make the service more efficient, more responsive and providing higher standards of care. The stumbling block has often been in translating high ambitions into tangible results.

In this respect the jury is still out on the final report from Lord Darzi's NHS Next Stage Review. Few would argue that a focus on quality and professional involvement is anything other than a good thing – the question is whether the review contains the means to bring this about.

In a breakfast discussion at The King's Fund last week, Lord Darzi was clear that he was freeing up the system to produce something different – centrally driven performance management, with its focus on driving activity and meeting targets, would be replaced by a more sophisticated strategy that would strengthen the capability and capacity of local NHS leaders to deliver change.

No-one should doubt the sincerity of those who say they want to foster clinical engagement and move away from central control, with the government and the strategic health authorities (SHAs) saying they are determined to operate with a light touch. However, the review gives SHAs new responsibilities and they will have to be vigilant in limiting their role if they are not to stifle local innovation and responsibility.

The review outlines two vital devices to drive up standards: more and better information about clinical performance and a strengthening of existing incentives.

The NHS has been painfully slow in adapting to the information revolution. Collecting and publishing data on the quality of care and on patient outcomes and experience does have the potential to drive up standards if the measures are right and clinicians are engaged.

It should help to encourage a culture of self-improvement as well as giving commissioners the data they need to have meaningful conversations about the quality of care.

Data on outcomes should also help patients to make informed choices and put pressure on providers to improve, while greater transparency on clinical quality will highlight variations in performance.

A number of the financial incentives proposed by Lord Darzi are worth trying out, such as rewarding and paying more for higher quality care and setting the Payment by Results tariff at the best practice rather than average price. Further work will be needed in developing the primary care Quality and Outcomes Framework and making practice income more dependent on attracting and retaining patients.

Much of the review builds on current reforms such as regulation, choice and a commitment to diversity of supply. The precise impact of many of these remains uncertain – the review's success will hinge on whether or not they are used to transform patient care.

What is clear is that delivering this agenda will demand cultural change at all levels – for too long the NHS has looked to the centre rather than out to its patients and their communities. The performance management arrangements have conditioned a whole system to operate within an environment in which goals have been set elsewhere and accountability through the national chain has been paramount.

A new performance regime will make demands on leaders at local level, who will need to be innovative, creative and willing to take risks. Organisations accustomed to doing only the bare minimum will fail to turn round poor or average performance.

Many NHS organisations have the right leaders in place but years of command and control will have left some without the right skills and approach. The review promises significant investment in leadership skills and that will be essential – all high-performing health systems internationally indicate this is the case. 

Genuine cultural change on this scale takes time – and it is important that the political world understands this and does not become impatient.

Transformational change is what the next decade should be all about. Lord Darzi's review has made the right start by going with the grain of reform. His review may not live up to its 'once in a generation' billing but it does what it set out to – it takes us to the next stage in NHS reform.

This article was originally published in The King's Fund bi-monthly update, July 2008


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