The likely impact of the Darzi review - Health Policy Today 28th June 2008

Tom Smith on the impact of Lord Darzi’s Next Steps review.

What are the chances of the Darzi review changing the terms of debate on NHS reform?  Despite the political gloom that has engulfed the government over recent weeks - and the Prime Minister in particular - this edition of Health Policy Today looks at the potential for the Next Steps review, due to be published on Monday afternoon, to help the government shift debate away from its political failings and onto its reform agenda.

Can Gordon Brown shift the terms of the debate onto reform?

Every newspaper has published features on Gordon Brown’s first year as Prime Minister and none are particularly positive.  According to a Telegraph / YouGov poll published yesterday, ‘only 16% think Labour will win, and 67 per cent say the Conservatives will form the next Government’.

The Times' political editor, Peter Riddell says that from this position, there is only one ‘sensible response’.  The Government must prove it ‘has not given up on reform’ and regain the policy initiative.  This is not easy for Brown to achieve, partly because he began by distancing himself from Tony Blair and then because he appeared to return, hence the ditherer charge. In some areas there seemed to be a retreat while in others, reform continued.  Riddell says the message has been ‘blurred’.

The Darzi review is an opportunity to relaunch and set out a post-Blair agenda, and Riddell sees evidence that the approach to reform is evolving beyond the Blairite view.  He points the Cabinet Office report published on Friday – Excellence and Fairness: Achieving World Class Public Services.  In his foreword, ‘Mr Brown talks of guaranteeing minimum standards and of user control.  This is not just about choice and competition though there will be new public sector and voluntary providers, as we will see in the Darzi report on Monday’.  The real theme for Riddell is that ‘the accountability of collectively provided services...will be strengthened’.

It will not be easy for the government and Gordon Brown to focus public debate on policy ideas. Riddell writes, 'however often he talks about long-term challenges, nuclear power, planning etc, the focus remains on his flaws as a leader and his many errors in office.  As John Major found in the mid-1990s, it is very hard to shift the public debate’.

The Darzi report is very important to the fortunes of the government

The publication of the Next Stage Review on Monday will present an opportunity for the Government to focus political debate on public service reform.  They seem confident that they can beat the opposition on policy grounds, particularly because they are able to position themselves as champions of reform and the opposition as against it.

In advance of Monday’s report, more details are emerging of what is likely to be in the Darzi report.  If the FT is right, as Nicholas Timmins so often is, one of the headlines the Government will hope to see widely reported is the placing within the constitution of ‘a legal right’ of choice for patients.   According to Timmins, ‘ministers believe that  enshrining this right in law... will underline its permanence and in time make it easier for patients with long-term conditions, for example, to choose which individual should take overall responsibility for managing their care.’

Will we see the growth of social enterprise in the NHS?

Healthcare Republic reported that the Darzi review will include a firm commitment to scrap the MPIG.  This will mean that practice income is more closely related to the patients registered and how well their clinical needs are met.  The end of MPIG will leave practices with greater exposure to a change in the numbers of registered patients.  If individuals leave a practice there will be a resultant decrease in income.

But competition to GPs may not only be from other practices.  Some of the proposed changes could see competition from nurse-led care groups.

On Friday the 27th June, The Independent was keen to emphasise that the Darzi review is likely to ‘propose a big boost in the size of independent nurse-led provision of primary care’.  In practical terms, groups of nurses will be able to set themselves up in independent organisations.  This has been talked about for some time, but a barrier to it happening has been the threat of losing pension rights, making it unattractive for clinicians to leave the NHS.  Darzi will propose that ‘nurses transferring from the NHS to a not-for-profit sector should not lose their pension rights’.  

The Independent notes that although 150,000 people work in community health services, only a very small number work in social enterprises.  ‘But with these new freedoms, the government expects the number to increase significantly'.  

In a foreword to the Cabinet Office report, mentioned above, Gordon Brown says he anticipates a big extension in the role of independent non-profit organisations.  

Over the coming weeks, we can expect to hear more about emerging ideas for groups of clinicians to form new kinds of organisations to deliver care.  The government will be able to respond to accusations that they favour centralised control by saying it is creating the mechanisms for clinicians to lead change.  Gordon Brown has reportedly been talking about ‘ushering in a new approach to professionalism’.

The Telegraph says ‘the aim is to give nurses much more control over how they work’.  The Independent speculates that the move could turn the traditional tables with groups of nurses employing doctors .

RCGP set out more details around their proposed ‘federated practice’ model

The Darzi report will usher in opportunities for change in primary care:  groups of nurses may form new community organisations, we are likely to see some hospital make moves to deliver community care.  We will also see GPs start to group together in new ways.

An important question is whether a whole range of different models will flourish alongside one another or whether uncertainties between professionals will mean that groups are cautious about new initiatives.  There is also a risk that different groups will have quite different visions of how services will develop and that these might clash.

Last September, the Royal College of GPs issued a ‘roadmap for general practice’, in which they first mooted their idea of a Primary Care Federation.   A report this week provides more detail.  

A report in Pulse explains that ‘under the proposals, groups of neighbouring practices would form federations with a formal legal structure, an executive management team and a written public constitution.  The federations would be overseen by a management board, comprised not only of GPs but also patient representatives.’

The College is trying to place itself midway between the Government and BMA positions.  RCGP chair, Steve Field said, “It is time for the profession and the Government to embrace a new way of working.  The traditional small business model of general practice is unsustainable in the long term but in seeking to replace it we must not throw out the baby with the bathwater”.

It is interesting that Royal Colleges and groups of consultants, GPs and nurses are now proposing new models of organising the way they deliver care.  If the Darzi report gives a green light to local experimentation there are a number of models to be talked through and experimented with.

What will be the impact of the Next Steps Review?

Although it did not seem possible just a few weeks ago, the publication of the Darzi report, with its focus on local innovation and opportunities for clinicians may be able to move debate on from the current political impasse.  The period in which Darzi has reviewed the next steps for the NHS has been a very political one, but it has focused the minds of clinicians and managers on how services might be delivered differently.

The next challenge is about how different visions of change will be accommodated locally. This is also likely to be a very political process, and will not be straightforward.  The success of Darzi’s review will be judged by whether it reinvigorates the reform process.

At the recent NHS Confederation conference, proceedings begin by debating important figures in the history of the NHS, people like Bevan, Beveridge and the like.  What are the chances when we meet again to celebrate the 70th anniversary that Darzi’s name might at least make the longlist of influential figures in the history of the NHS?