The final report of Lord Darzi of Denham’s “next stage review” was hailed as a “once in a generation opportunity to improve the NHS” by Prime Minister Gordon Brown. This makes it at least the fourth “once in a generation” report on the health service in the past decade.

New Labour’s first white paper, The New NHS: modern dependable was given this billing, as was The NHS Plan that followed two years later and the Our Health, Our Care, Our Say blueprint for community services that came out in 2006. However, High Quality Care for All may be the first health service plan for the digital generation.

Starting from here

Like his predecessors, Darzi opens his final report with an analysis of where the NHS is now and the challenges it faces in the 21st century. Most of these challenges are familiar: rising expectations, an ageing society, the changing burden of disease (from acute to chronic conditions) and advances in treatment.

However, two are new; at least in terms of the context and the prominence they are given. These are “the continuing development of our information society” and “the changing expectations of the health workplace.”

Darzi makes much of these. “By 2012, 74 per cent of UK homes are expected to have broadband internet access, transforming how people will seek and use information in their lives,” he writes.

“The implications for health and healthcare are profound. People are able to quickly and conveniently find information about treatment and diseases in a way that was previously impossible. They are able, and want, to engage with others online, sharing information and experiences.”

One of the biggest issues that Darzi identifies is how the health service can provide people with good information and interact with them in the way they want; while also responding to staff demands for “high quality”, well skilled and well supported work.

Many of his specific recommendations grow out of these concerns. High Quality Care for All promises a raft of web-based services to give patients more control over their health and treatment.

It also promises a new portal mystaffspace, to give employees access to common IT systems, including NHSmail, and to new best-practice and quality services, some of which will be peer-based.

Plans for reform

In this, the Darzi report bears some resemblance to The NHS Plan, which also looked to technology to help “a 1940s service” into the “21st century world.” A decade on, however, it goes much further than the plan could.

The NHS Plan promised to develop electronic patient records so that staff could “maintain continuity of care and knowledge of their patients.” It promised to make existing services a bit more convenient with “airline style booking.” And it looked to the telephone for its one, new 24-hour service – NHS Direct.

High Quality Care for All says the HealthSpace feature of NHS Choices will be developed so that patients not only have access to their records, but can add test and other results.

Additional features of NHS Choices will be developed so that patients can register with a GP online and store personal care plans. And the report puts a new focus on self-care supported by information and tele-medicine.

“We want patients to make the right choices for themselves and their families,” it says. “The first step was taken with the launch of the NHS Choices website… the next stage is to empower patients with clear information on the quality of each service offered by every NHS organisation – across all settings of care.”

More information, more choice

High Quality Care for All wants to drive information and choice in two directions in particular. The first is back into primary care. This would answer a common criticism of The NHS Plan, that it should have focused on giving patients a choice of purchaser or advisor, rather than elective care provider.

The Darzi report notes that while “people can choose what GP practice to register with” now, in practice their choice is restricted by a lack of information about what services are available and by closed lists.

It proposes that people should be given more information about GP services – not least by giving “local NHS information packs” to new home owners. It also proposes that people should be able to register with a practice through the NHS Choices website and that GP income should be more closely tied to list size.

The second is out into long-term care. The Our Health, Our Care, Our Say white paper started to give people with multiple and long-term conditions more intensive support, but Darzi pushes its agenda much further.

His report says the Department of Health will publish a patient’s prospectus “by the end of the year” that will set out the local choices that should be available for people living with long-term conditions.

The “personal care plan” approach that has been applied in mental health services will be rolled out to 15 million people with long-term conditions within two years. And the government will pilot personalised budgets, which have already been tried in social care, from next year.

These reforms worry some commentators. Dr Anna Dixon, King’s Fund director of policy, says some patients could exhaust their budgets – while others might choose to top them up, “creating a two-tier health service that would undermine one of the founding principles of the NHS.”

However, they could give patients much more control. And by making the cost of certain options more explicit, they could act as a significant driver for the development of some new services, such as telehealth and telecare.

Driving quality

High Quality Care for All is also clearer than some of the earlier “once in a generation” reports about the purpose of choice. It sees informed choice – or choice based on good information – as a driver of quality. It also proposes that the range of information available should be greatly extended.

Patients will be able to feed back their experiences through NHS Choices and “patient reported outcome measures” (PROMS) will be developed. Indeed, the importance of patient feedback is emphasised by the draft NHS Constitution that was published alongside the report.

This proposes that while patients should gain a number of rights – including a right to information and a right to choice – they should also have a number of responsibilities – including the responsibility to “provide feedback” on the care they receive.

Meanwhile, a small percentage of trust income will be tied to PROMS and other quality measures. Again, Darzi envisages that things will develop quickly. His report says that trusts will have to start submitting quality information by 2009 and that payments will be introduced from 2010 – unless commissioners want to move faster.

In other words, this potentially major shift in how quality is assessed and services paid for could happen before the next general election, when the Conservative Party is also planning to campaign on more information and better “outcome” measures for the NHS.

More change ahead

Reaction to the Next Stage Review’s final report has been surprisingly muted, perhaps because it emerged during the NHS’ 60th anniversary celebrations, perhaps because it continues many of the themes of similar documents, perhaps because it can look like a portmanteau of ideas and pledges.

Certainly many think-tanks and pressure groups have chosen to comment on individual sections or bug-bears, rather than on the report as a whole. Yet it has some interesting things to say about how technology is changing the environment in which the NHS operates and how technology might be used to drive change and quality.

Steve Barnett, acting chief executive of the NHS Confederation said: “We think the combination of three powerful ideas running through the report could make a major difference: patients being aware of their rights, choices and information; industrial scale feedback and measurement of quality and patient experience; and, capitalising on the motivation of NHS professionals to provide the best possible care with peer review and competitiveness.”

And King’s Fund chief executive Niall Dickson said: “This will be a new era in which patients will be able to check on the quality of the services they are being offered. This should help us all make more informed choices and put pressure on those providing the care to do better.”


High Quality Care For All