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Health Unit: Response to Lord Darzi’s final report: A grand vision but the system will work against it

Lord Darzi today publishes his eagerly awaited Next Stage Review of NHS policy.

Ostensibly it heralds the end of the top-down era; a shift away from central targets to more self-sustaining means of driving performance, based on user-empowerment, information, choice and competition. The following measures are welcome:

  • Extending the right of patients to choose their GP and reaffirming the right for elective treatment.
  • The introduction of pilot schemes for individual budgets for patients with long-term conditions.
  • The pledge to publish extensive data on outcomes – including those self-reported by patients (PROMS) – and to link payment to this.
  • ‘Pension passports’ to encourage the potential for social enterprise to be realised. This as an area of almost wholly untapped potential between the state and the individual.
  • The emphasis on strong, GP-led, commissioning, clinical leadership and the announcement of integrated care pilots.

All, in theory, have real potential dramatically to improve responsiveness, outcomes and patient experience. Lord Darzi is entirely correct in focusing on quality, not quantity; a quality service is, after all, what matters to patients.

Reality check

However, Lord Darzi’s vision – as he admits – requires an environment where health professionals are empowered to lead change and where patients are much more than just passive recipients of care.

He writes: ‘it has been clear that change cannot be mandated from the centre – it requires the unlocking of the talents of frontline staff’.

But as previous Civitas reports have shown, the structure of the NHS works against this. The ‘customer’ has always been the government, not the patient, with massively perverse consequences.

Performance has been driven by targets, central direction and political imperative. New reform initiatives have come with alarming frequency and – often ill-thought through and partially contradictory – have militated against high quality, personalised care.

This point was raised time and time again by service providers and health and social care professionals in the series of debates Civitas hosted on Lord Darzi’s review.

The NHS must move away from the mantra of central planning to an environment in which money is in patients’ hands and professionals are empowered to develop new models of working and create holistic services right for the individual.

Yet the nine regional reports by Strategic Health Authorities (SHAs) accompanying Lord Darzi’s national review confirm that the centralised approach is here to stay.

The reports are highly prescriptive, dominated by:

  • Access targets, such as waiting times for mental health services, therapy (NHS East of England; NHS East Midlands) and diagnostic tests (NHS South West).
  • Demands on service configuration, such as urgent care centres (NHS East of England; NHS North West), diagnostics on the high street (NHS South East Coast) and an increased role for pharmacy (NHS Yorkshire & Humber).
  • Descriptions of process, such as annual GP health checks (NHS East Midlands), the use of care coordinators (NHS West Midlands) and ‘opportunities for prevention’ (NHS South Central).

Lord Darzi’s own report also requires PCTs to develop ‘strategic plans for delivering the visions’; a time-consuming task that will divert attention from the job in hand.

The national report also:

  • Reaffirms the provision for 150 new GP-led health centres, despite the extremely poor record of centrally-planned infrastructure over the past 10 years.
  • Introduces a National Quality Board, along with provisions for regional quality boards and a ‘Quality Observatory’. Yet the DH already produces several ‘toolkits’ and ‘high-impact changes’; as does the National Institute for Innovation and Improvement. Their impact has been marginal.

Evidence-based medicine is important, but prescription will inevitably focus the attention of commissioners on meeting measures set by unaccountable central bodies, rather than reaching out to their populations to develop genuinely patient-centred services. A one-size-fits-all approach will only produce the equality of the mediocre.

A new paradigm

For Lord Darzi’s vision to work, it needs to be based on the principle that the individual, not the government, should be in charge.

The government should maintain the emphasis of Lord Darzi’s report on clinical quality and patient experience, but recognise this will only come through the customer being the patient, not the state.

This requires reform of funding as well as provision. We should be working towards a system where each and every patient has a risk-adjusted budget – largely tax-funded – to choose between competing commissioners (GP-led, PCTs or insurers) as well as providers.

James Gubb, Director of the Health Unit at Civitas, said: ‘In his 1942 report that paved the way for the NHS, Sir William Beveridge was at pains to emphasise that “in organising security, the state should not stifle incentive, opportunity and responsibility”.

‘Yet in their direction of the NHS, successive governments have done exactly this. On its 60th birthday, Lord Darzi’s report offers an enticing vision, but it is clear that the government – be it through the DH or SHAs – will still be calling the shots.

‘If there is one lesson from the past 10 years, it is that this is no way to run a health system. Service developments are best driven by user empowerment, not top-down pressure’.

Notes to authors:

  • i. The unit aims to facilitate informed discussion on health issues, bringing fresh thinking to the problems facing the NHS and focusing squarely on what matters: patient-centred, safe and integrated health care provided by empowered professionals. See here


For more information ring:
James Gubb 020 7799 6677 (w) or 07930 243570 (m)



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