Editor's blog 1 July 2008: 'High-quality care for all': thoughts on the Darzi review

Editor's blog: Reviewing the Darzi review

Andy Cowper, editor, Health Policy Insight

If you agree that clinical engagement is the main aspect needed to improve the NHS’s performance, then the launch of the Darzi review High-quality care for all (www.dh.gov.uk) might give you some hope.

Yet that hope is more about the document’s rhetoric and tone than about its content. Its hugely ambitious aim is to change culture, and to see the NHS being locally led.

Greatest hits
In terms of its hard content, the review actually contains relatively little that is, strictly speaking, new. More outcome measurement was already on its way in an appendix of the 2008-9 operating framework, but it wasn’t widely noticed.

On page 63, the report even re-announces the FESC! As discussed here on Sunday, many significant policy aspects announced in the review are in fact already policy. (There are some exceptions, discussed below).

However, they are widely flouted policy. Choice of GP already, in theory, exists. It isn’t encouraged by GPs because they don’t initially get 100% payment when they take on new people to their lists.

Likewise, PCTs have already got to consider paying for drugs not approved by NICE and are instructed to implement NICE guidance within months: they just don’t do it, by and large. Or on drugs, they generally conclude that the answer is ‘no’ or ‘not yet’.

Some unexpected areas
There were surprises. The first is the draft NHS Constitution’s legally enshrining the right to choice. This might well be less than it seems, however: read the draft constitution closely, and you find the choice is more a right to express a preference for a particular GP and for the practice to “try to comply”.

Lord Darzi was also repeatedly clear at the launch that in the acute sector, choice will be only that of surgical team; not of surgeon.

And nobody I was talking to foresaw NICE’s mega-expansion and assuming the responsibility for NHS Evidence. Which sounds lovely. There was, of course, this very good resource along similar lines called Best Treatments, run by the BMA / BMJ. You may remember it. And what happened to that? Oh yes, the DH stopped its funding.

Following the money
The financial changes may prove the most important. By 2010, up to 3% of acute trusts’ income will be conditional on the new quality and outcome measures.

3% is not a huge amount, but is probably a sensible level at which to start until confidence in the quality and outcome data is developed.

The abolition of the GPs’ Minimum Practice Income Guarantee (MPIG), to be replaced by more QOF funding, will be of particular interest. The ‘p’ word (polyclinics) may have been banished from departmental and ministerial vocabularies, but Darzi remains clear on access: “we will develop a fairer funding system, ensuring better rewards for GPs who provide responsive, accessible and high quality services”.

The funding of training is interesting. The much-raided multi-professional education and training (MPET) budgets should step forward and take a bow for reducing NHS deficits over the past few years. It is their final curtain, to be replaced by a tariff-based system where the funds follow the trainee. The document knows the chequered history of MPET budgets, stating “we are reforming the funding of education and training to make it fairer, more transparent and ensure that it is used for the purpose for which it is intended.”

So will these budgets still sit with the SHAs? If not, will it make future deficits harder to hide? This could prove a problem ahead for over-hospitaled or multi-site-rich areas.

A focus on quality
The extent to which the rhetoric and tone of the document focus on quality will undoubtedly have been influenced by the most recent Healthcare Commission staff survey - which found that 54% of staff surveyed did not believe that quality of patient care was the top priority. It also found that only 26% of staff were ‘satisfied or very satisfied’ with the extent to which their trust values their work (down from 28% in 2005).

Some confusions
The report makes much of the fact that it introduces no new national targets and no restructuring. This is not really true, as the PCTs who have to produce a 5-year strategic plan by next Spring will tell you – that is very much a national target.

Moreover, the national quality board and SHA quality observatories sound quite like new bits of structure to me.

The report also states, “we will complete work on a standard, but flexible, contract to enable commissioners to hold community health services to account for quality and health improvement”: one of a handful of mentions of commissioning, and sounding a bit like central diktat. Interestingly, it also suggests “We will also increase transparency by moving away from ‘block contract’ funding”.

It promises that PCTs will have a two-year allocation later this year, which will help planning. But the reforms will also, however, not be cost-neutral on the basis of the experience of previous reforms. Agreeing the quality thresholds for the incentive payments will be fiendishly hard. There will be increased temptations to game audit data.

Commissioning news? A little confused
Hurrah for commissioning. The wise move to including outcome and patient satisfaction measures under the ‘Commissioning for Quality & Innovation’ (CQUIN) scheme “will encourage all NHS organisations to pay a higher regard to quality. It will be a simple overlay to the Payment By Results system, forming part of commissioning contracts. Funding will be freed up through reducing the tariff uplift from 2009 to give commissioners dedicated space to pay for improved outcomes. Providers will be rewarded in the first year for submitting data. From no later than 2010, payments will reward outcomes under the scheme. The scheme will be fl exible to suit local circumstances. Where PCTs want to go faster, they will be able to apply the principles as soon as they wish. The scheme will be subject to independent evaluation so that it improves as it matures”.

All of that sounds good, and it even includes assessment. That’s a gold star!

But all is far less clear later on. Point 26 on page 53 is worth quoting in full: “Locally, primary care trusts, on behalf of the populations that they serve, should challenge providers to achieve high quality care. This will require stronger clinical engagement in commissioning. This must go beyond practice-based commissioning and professional executive committees to involve all clinician groups in strategic planning and service development to drive improvements in health outcomes.”

It goes on to say that the World-Class Commissioning programme will deliver this … through holding PCTs to account for their commissioning under the new assurance process.

Is it just me? Firstly, doesn’t that sound like central control by the DH being displaced to the WCC team – excellent people as they are to a man and woman?

Secondly, and as someone who believes commissioning may be just what we need, I’m wildly unclear how the assurance process will be a guarantor of universal system-wide clinical engagement. Maybe the primary care strategy will reveal all? I hope so.

Final thoughts
The vision is exciting, and the focus on quality is ambitious. It also represents concerted bridge-building with the clinical professions that has been urgent for some years now.

These plans will succed or fail on the basis of local leadership and engagement in the projects. If SHA plans have been grass-roots documents, areas could leap ahead fast. However, it remains to be seen whether the centralisers throughout the NHS at various levels have it in them to learn to let go. It will not be easy.

Control – or the illusion thereof – is a powerful and addictive hallucinogen.