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High Quality Care For All

NHS Next Stage Review Final Report Summary


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DH INFORMATION READER BOX

Policy Estates

HR / Workforce Commissioning

Management IM & T

Planning / Performance Finance

Clinical Social Care / Partnership Working

Document Purpose Policy

Gateway Reference 10106

Title High Quality Care For All

NHS Next Stage Review Final Report

Author Professor the Lord Darzi of Denham KBE, HonFREng, FmedSci

Publication Date 30 Jun 2008Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Foundation Trust CEs ,

Medical Directors, Directors of PH, Directors of Nursing, Local Authority CEs,

Directors of Adult SSs, PCT PEC Chairs, NHS Trust Board Chairs, Special HA CEs,

Directors of HR, Directors of Finance, Allied Health Professionals, GPs,

Communications Leads, Emergency Care Leads, Directors of Children's SSs

Circulation List

Description Final report of Lord Darzi's NHS Next Stage Review. It responds to the 10 SHA

strategic visions and sets out a vision for an NHS with quality at its heart.

Cross Ref Framing Document - May 2008

Interim Report October 2007

Superseded Docs Update

Action Required N/A

Timing N/A

Contact Details

SW1A 2NS

http://www.nhs.uk/ournhs

020 7210 3000

NHS Next Stage Review Team

Department of Health

Room 544, Richmond House

79 Whitehall, London

Email: [email protected]

For Recipient's Use
http://www.nhs.uk/ournhsmailto:[email protected]://www.nhs.uk/ournhsmailto:[email protected]


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1High Quality Care For All NHS Next Stage Review Final Report

Summary letterOur NHS Secured today for future generationsby Lord Darzi

An NHS that gives patients and thepublic more information and choice,works in partnership and has quality ofcare at its heart.

Dear Prime Minister, Chancellor ofthe Exchequer, and Secretary of Statefor Health,

This year the NHS is 60 years old.We are paying tribute to a servicefounded in adversity, from which wereestablished enduring principles of equalaccess for all based on need and notability to pay. We are celebrating anational institution that has made animmeasurable difference to millions ofpeoples lives across the country.

Quite simply, the NHS is there when weneed it most. It provides round the clock,compassionate care and comfort. It playsa vital role in ensuring that as many of usas possible can enjoy good health for aslong as possible one of the things thatmatters most to us and to our family and

friends.

The journey so far

I know the journey we have all beenon from my own experience as anNHS clinician working in partnershipwith professional colleagues acrossthe service.

I used to be the only colo-rectal surgeon

in my hospital; today I am a member of

a team of four surgeons, working in anetwork that reaches out into primarycare. Ten years ago, we had one part-time stoma nurse. Today we have twofull-time stoma nurses, two specialist

nurses and a nurse consultant.

Ten years ago, my patients wouldsometimes wait over a year fortreatment, and now they wait just afew weeks and even less if cancer issuspected. My patients are treated usingkeyhole surgery enabling them to leavehospital in days rather than weeks.My teams conversations about quality

take place in weekly multidisciplinarymeetings rather than in corridors.Together, these changes have meantreal improvements for patients.

I have seen for myself the NHS gettingbetter, and I have heard similar storiesfrom other clinical teams throughout thecountry over the course of this Review.These achievements were enabled bythe investment of extra resources,1 bygiving freedom to the frontline throughNHS foundation trusts, and by ensuringmore funding followed patient choices.They were delivered by the dedicationand hard work of NHS staff who weredetermined to improve services forpatients and the public.

1 In 1996/7, the budget for the NHS in England was33 billion; in 2008/9 it is 96 billion.


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2 Summary

The next stage of the journey

My career is dedicated to improvingcontinuously the quality o care weprovide or patients. This is what inspiresme and my proessional colleagues, andit has been the guiding principle or thisReview. We need to continue the NHSjourney o improvements and moverom an NHS that has rightly ocused onincreasing the quantity o care to onethat ocuses on improving the quality

o care.

There is still much more to do to achievethis. I have continued my clinical practicewhile leading the Review nationally.I have seen and treated patients everyweek. Maintaining that personalconnection with patients has helped meunderstand the improvements we stillneed to make. It has driven me to ocus

this Review on practical action.

It is because o this that I have beenjoined in this Review by 2,000 cliniciansand other health and social careproessionals rom every NHS region inEngland. Their eorts, in considering thebest available evidence and in setting outtheir own visions or high quality services(described in Chapter 1), have been thecentrepiece o this process.

Their visions developed in discussionwith patients, carers and members othe general public set out bold andambitious plans. I am excited by thelocal leadership they demonstrate andthe commitment o all those who havebeen involved.

In developing the visions, the NHS has

had to ace up to signicant variationsin the quality o care that is provided.

Tackling this will be our rst priority.

The NHS needs to be fexible to respond to the needs o local communities, but people need to be condent thatstandards are high across the board.

Delivering the visions will mean tacklinghead on those variations in the quality o care and giving patients more inormation and choice. The messagethey send is that the programme o

reorm that has been put in place has been unevenly applied and can go much urther.

We also need to accelerate change or other reasons. Chapter 2 describes the changes acing society and healthcare systems around the world. It sets out how the NHS in the 21st century aces a particular set o challenges, which I

would summarise as: rising expectations; demand driven by demographics; the continuing development o our inormation society; advances in treatments; the changing nature o disease; and changing expectations o the health workplace. These are challenges we cannot avoid. The NHSshould anticipate and respond to the challenges o the uture.

My conclusions, and the measures described in this report, ocus on how we can accelerate the changes that rontline sta want to make to meet those challenges, whilst continuing to raise standards.

The vision this report sets out is o an NHS that gives patients and the public more inormation and choice, works in

partnership and has quality o care at its heart quality dened as clinically


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eective, personal and sae. It will see

the NHS deliver high quality care or allusers o services in all aspects, not justsome. I set out below the key steps wemust take to deliver this vision.

High quality care or patients andthe public

Throughout this Review, I have heardclearly and consistently that people wanta greater degree o control and infuence

over their health and healthcare. Ianything, this is even more important orthose who or a variety o reasons ndit harder to seek out services or makethemselves heard.

Personalising services means makingservices t or everyones needs, notjust those o the people who make theloudest demands. When they need it,

all patients want care that is personalto them.2 That includes those peopletraditionally less likely to seek help orwho nd themselves discriminatedagainst in some way. The visionspublished in each NHS region makeclear that more support is needed orall people to help them stay healthyand particularly to improve the healtho those most in need. Chapter 3explains how we will do this including byintroducing new measures to:

Create an NHS that helps peopleto stay healthy. For the NHS to besustainable in the 21st century it needsto ocus on improving health as well astreating sickness. This is not about thenanny state. As a clinician, I believe that

2 Opinion Leader Research, Key ndings o 18

September 2007 Our NHS, Our Future nationwideconsultative event.

the NHS has a responsibility to promote

good health as well as tackle illness.

Achieving this goal requires the NHSto work in partnership with the manyother agencies that also seek to promotehealth. Much progress on closer workinghas been made in recent years. In linewith my terms o reerence,3 this reportsocuses on what the NHS can do toimprove the prevention o ill health.

The immediate steps identied by thisReview are:

Every primary care trust willcommission comprehensivewellbeing and preventionservices, in partnership with localauthorities, with the servicesoered personalised to meet

the specifc needs o their localpopulations. Our eorts must beocused on six key goals: tacklingobesity, reducing alcohol harm,treating drug addiction, reducingsmoking rates, improving sexual healthand improving mental health.

A Coalition or Better Health, witha set o new voluntary agreementsbetween the Government, private

and third sector organisationson actions to improve healthoutcomes. Focused initially oncombatting obesity, the Coalitionwill be based on agreements toensure healthier ood, to get morepeople more physically active, and toencourage companies to invest morein the health o their workorce.

3 Terms o Reerence available atwww.ournhs.nhs.uk
http://www.ournhs.nhs.uk/http://www.ournhs.nhs.uk/


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4 Summary

Raised awareness o vascular riskassessment through a new ReduceYour Risk campaign. As we rollout the new national programme ofvascular risk assessment for peopleaged between 40 and 74, we willraise awareness through a nationwideReduce Your Risk campaign helpingpeople to stay healthy and to knowwhen they need to get help.

Support or people to stay healthyat work. We will introduce integratedFit for Work services, to help peoplewho want to return to work but arestruggling with ill health to get backto appropriate work faster.

Support GPs to help individualsand their amilies stay healthy.We will work with world-leading

professionals and patient groups toimprove the Quality and OutcomesFramework to provide better incentivesfor maintaining good health as well asgood care.

We will give patients more rights andcontrol over their own health and care.I have heard the need to give patientsmore information and choice to makethe system more responsive to their

personal needs. We will:

Extend choice o GP practice.Patients will have greater choice ofGP practice and better information tohelp them choose. We will developa fairer funding system, ensuringbetter rewards for GPs who provideresponsive, accessible and high qualityservices. The NHS Choices website will

provide more information about all

primary and community care services,so that people can make informedchoices.

Introduce a new right to choice inthe frst NHS Constitution. The draftNHS Constitution includes rights tochoose both treatment and providersand to information on quality, so that,wherever it is relevant to them, patients

are able to make informed choices.

Ensure everyone with a long-termcondition has a personalised careplan. Care plans will be agreed by thepatient and a named professional andprovide a basis for the NHS and itspartners to organise services aroundthe needs of individuals.

Pilot personal health budgets.Learning from experience in social careand other health systems, personalhealth budgets will be piloted, givingindividuals and families greatercontrol over their own care, withclear safeguards. We will pilot directpayments where this makes mostsense for particular patients in certaincircumstances.

Guarantee patients access to themost clinically and cost eectivedrugs and treatments. All patientswill receive drugs and treatmentsapproved by the National Institute forHealth and Clinical Excellence (NICE)where the clinician recommends them.NICE appraisals processes will bespeeded up.


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The common theme o these new

measures or patients is improvingquality. It must be the basis o everythingwe do in the NHS.

Quality at the heart o the NHS

In my career as a surgeon, I try to domy best to provide patients with highquality NHS care just like hundredso thousands o other sta. This hasbeen my guiding principle as I have led

this Review.

High quality care should be as saeand eective as possible, with patientstreated with compassion, dignity andrespect. As well as clinical quality andsaety, quality means care that is personalto each individual.

As independent research has shown,4

the NHS has made good progress overthe past decade in improving the overallquality o care or patients. During thisperiod, improvements in quality wereocused primarily on waiting times,as basic acceptable standards o accessto A&E and secondary care wereestablished, and on stafng levels andphysical inrastructure.

Today, with the NHS budget approaching2 billion a week, more sta, andimprovements in the quality andavailability o inormation, quality can beat the heart o everything we do in theNHS. It means moving rom high quality

4 S Leatherman and K Sutherland, The Quest orQuality: Refning the NHS Reorms, NufeldTrust, May 2008 and K Davis et al., Mirror, Mirroron the Wall: An international update on the

comparative perormance o American healthcare,Commonwealth Fund, May 2007.

care in some aspects to high quality care

in all.

We will raise standards. The visions setout or each NHS region and ormed bypatients expectations are ambitious orwhat the NHS can achieve. Chapter 4 othis report sets out the measures that willenable us to meet these standards:

Getting the basics right frst time,every time. We will continue to seekimprovements in saety and reductionsin healthcare associated inections.The Care Quality Commission will havenew enorcement powers. There willbe national campaigns to make careeven saer.

Independent quality standardsand clinical priority setting. NICE

will be expanded to set and approvemore independent quality standards.A new National Quality Board willoer transparent advice to Ministerson what the priorities should be orclinical standard setting by NICE.

For the frst time we willsystematically measure and publishinormation about the qualityo care rom the rontline up.

Measures will include patients ownviews on the success o their treatmentand the quality o their experiences.There will also be measures o saetyand clinical outcomes. All registeredhealthcare providers working or, or onbehal o, the NHS will be required bylaw to publish Quality Accounts justas they publish fnancial accounts.


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6 Summary

Making unding or hospitalsthat treat NHS patients refectthe quality o care that patientsreceive. For the frst time, patientsown assessments o the success otheir treatment and the quality o theirexperiences will have a direct impacton the way hospitals are unded.

For senior doctors, the currentClinical Excellence Awards Scheme

will be strengthened, to reinorcequality improvement. New awards,and the renewal o existing awards,will become more conditional onclinical activity and quality indicators;and the Scheme will encourage andsupport clinical leadership o servicedelivery and innovation.

Easy access or NHS sta toinormation about high qualitycare. All NHS sta will have accessto a new NHS Evidence service wherethey will be able to get, through asingle web-based portal, authoritativeclinical and non-clinical evidence andbest practice.

Measures to ensure continuousimprovement in the quality oprimary and community care. We

have just completed our consultationon proposals to bring all GP practicesand dental practices within the scopeo the new health and adult socialcare regulator, the Care QualityCommission.5 We will introduce a newstrategy or developing the Qualityand Outcomes Framework whichwill include an independent and

5 Department o Health, The future regulation ofhealth and adult social in England, 25 March 2008.

transparent process or developing and

reviewing indicators. We will supportpractice accreditation schemes, likethat o the Royal College o GeneralPractitioners.

Developing new best practice tarisocused on areas or improvement.These will pay or best practice ratherthan average cost, meaning NHSorganisations will need to improve to

keep up.

We will strengthen the involvement oclinicians in decision making at everylevel o the NHS. As this Review hasshown, change is most likely to beeective i it is led by clinicians. We willdo this by ensuring that:

Medical directors and qualityboards eature at regional andnational level. These will complementthe arrangements at PCT level that aredeveloping as part o the World ClassCommissioning programme.

Strategic plans or delivering thevisions will be published later thisyear by every primary care trust.Change will be based on the fveprinciples I set out earlier this year in

Leading Local Change.6

There is clear local support forquality improvement. A new QualityObservatory will be established inevery NHS region to inform localquality improvement efforts.

6 NHS Next Stage Review: Leading Local Change,Department o Health, May 2008.


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We will foster a pioneering NHS.

Throughout my career, in all the clinicalteams I have worked in, my colleaguesand I have challenged one another toimprove the way we provide care forpatients. Continuous advances in clinicalpractice mean the NHS constantly hasthe opportunity to improve. My reviewwill enable this through:

Introducing new responsibilities,funds and prizes to support andreward innovation. Strategic healthauthorities will have a new legal dutyto promote innovation. New fundsand prizes will be available to thelocal NHS.

Ensuring that clinically and costeffective innovation in medicinesand medical technologies is

adopted. We will strengthen thehorizon scanning process for newmedicines in development, involvingindustry systematically to supportbetter forward planning and developways to measure uptake. For newmedical technologies, we will simplifythe pathway by which they passfrom development into wider use,and develop ways to benchmark andmonitor uptake.

Creating new partnershipsbetween the NHS, universitiesand industry. These clusters willenable pioneering new treatments andmodels of care to be developed andthen delivered directly to patients.

These changes will help the NHS toprovide high quality care across the

board. Throughout this Review, it has

been clear that high quality care cannot

be mandated from the centre itrequires the unlocking of the talents offrontline staff.

Working in partnership with staff

I have heard some people claim thatthere is change fatigue in the NHS.I understand that NHS staff are tired ofupheaval when change is driven top-down. It is for this reason that I chose

to make this Review primarily local, ledby clinicians and other staff working inthe NHS and partner organisations. Inmy own practice and across the countryI have seen that, where change is ledby clinicians and based on evidenceof improved quality of care, staff whowork in the NHS are energised by it andpatients and the public more likely tosupport it.

We will empower frontline staff to leadchange that improves quality of care forpatients. Chapter 5sets out how we willdo this by:

Placing a new emphasis onenabling NHS staff to lead andmanage the organisations in whichthey work. We will re-invigoratepractice-based commissioning andgive greater freedoms and supportto high performing GP practices todevelop new services for their patients,working with other primary andcommunity clinicians. We will providemore integrated services for patients,by piloting new integrated careorganisations, bringing together healthand social care professionals from arange of organisations community


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8 Summary

services, hospitals, local authorities and

others, depending on local needs.

Implementing wide rangingprogramme to support thedevelopment o vibrant, successulcommunity health services. WherePCTs and sta choose to set up socialenterprise organisations, transerredsta can continue to beneft rom theNHS Pension Scheme while they work

wholly on NHS unded work. We willalso encourage and enable sta to setup social enterprises by introducing asta right to request to set up socialenterprises to deliver services.

Enhancing proessionalism.There will be investment in newprogrammes o clinical and boardleadership, with clinicians encouraged

to be practitioners, partners andleaders in the NHS. We challenge allorganisations that do business as parto, or with, the NHS to give cliniciansmore control over budgets and HRdecisions.

No new national targets are set inthis report.

We will value the work o NHS sta.

NHS sta make the dierence where itmatters most and we have an obligationto patients and the public to enablethem to make best use o their talents.That is why the Review announces inChapter 6:

New pledges to sta. The NHSConstitution makes pledges onwork and wellbeing, learning and

development, and involvement and

partnership. All NHS organisations will

have a statutory duty to have regardto the Constitution.

A clear ocus on improving thequality o NHS education andtraining. The system will be reormedin partnership with the proessions.

A threeold increase ininvestment in nurse and midwie

preceptorships. These oer protectedtime or newly qualifed nurses andmidwives to learn rom their moresenior colleagues during their frst year.

Doubling investment inapprenticeships. Healthcare supportsta clinical and non-clinical are the backbone o the service.Their learning and development

will be supported through moreapprenticeships.

Strengthened arrangements toensure sta have consistent andequitable opportunities to updateand develop their skills. Sixty percent o sta who will deliver NHSservices in 10 years time are alreadyworking in healthcare.We need tomake sure that they are able to keep

their skills and knowledge up to date.

The frst NHS Constitution

You asked me to consider the case or anNHS Constitution. In Chapter 7, I set outwhy I believe it will be a powerul wayto secure the defning eatures o theservice or the next generation. I haveheard that whilst changes must be madeto improve quality, the best o the NHS,

the values and core principles which


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underpin it, must be protected and

enshrined. An NHS Constitution will helppatients by setting out, or the rst time,the extensive set o legal rights theyalready have in relation to the NHS. Itwill ensure that decision-making is localwhere possible and more accountablethan it is today, providing clarity andtransparency about who takes whatdecisions on our behal.

Finally, Chapter 8 sets out how we willdeliver this ambitious programme.

Conclusion

In the 21st century, there remains acompelling case or a tax-unded,ree at the point o need, NationalHealth Service. This Report celebratesits successes, describes where thereis clear room or improvement, looks

orward to a bright uture, and seeksto secure it or generations to comethrough the rst NHS Constitution. Theocus on prevention, improved qualityand innovation will support the NHSin its drive to ensure the best possiblevalue or money or taxpayers. It is alsoan excellent opportunity to pursue ourduties to promote equality and reducediscrimination under the Equality andHuman Rights Act.

Through this process, we have developeda shared diagnosis o where we currentlyare, a unied vision o where we want tobe and a common language rameworkto help us get there. This Review hasbuilt strong oundations or the utureo the service. It outlines the shape othe next stage o reorm, with the clarityand fexibility to give condence or the

uture.

Leadership will make this change

happen. All o the 2,000 rontline stathat have led this Review have shownthemselves to be leaders by havingthe courage to step up and make thecase or change. Their task has only justbegun it is relatively easy to set out avision, much harder to make it a reality.As they strive to make change happen,they can count on my ull support.

I would like to thank everyone who hasparticipated in this Review. I am grateulor the help they have given to me inorming and shaping the conclusions othis Report.

Best wishes,

Professor the Lord Darziof Denham KBEHon FREng, FMedSci

Parliamentary Under Secretary of State

Paul Hamlyn Chair o Surgery,Imperial College London

Honorary Consultant Surgeon,Imperial College Healthcare NHS Trustand the Royal Marsden HospitalNHS Foundation Trust


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darzi report

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