'High quality care for all: NHS Next Stage Review' final report

Lord Darzi was tasked with leading a widescale review of the NHS, to develop a vision of an NHS fit for the 21st century.

The review involved thousands of clinical, social care and health service professionals, and members of the public. The purpose of the report was to focus on what the NHS could do to improve the prevention of ill health, in partnership with other authorities and agencies.

The final report, High Quality Care for All, was published on 30 June 2008.

Quality of care

At the heart of the report was a focus on quality, which was defined as safe, effective and efficient care.

Darzi's focus on the involvement of clinicians in developing systems was critical.

He articulated the importance of focusing on outcomes, rather than targets. The proposal was that targets such as 18-week waits, that were once considered aspirational, would become established as minimum standards. In the future, national challenges would be met through minimum standards and commissioning decisions. There would not be additional top-down targets, beyond the minimum standards.

At a provider level, Darzi outlined plans to require NHS providers to publish quality accounts from April 2010, in the same way as they would publish financial accounts. The reports would provide information for the public on safety, experience and outcomes.

Darzi announced seven steps that would be needed to achieve higher quality care:

• bringing clarity to quality: developing a coherent approach to setting standards
• measuring quality: developing a quality measurement framework at every level
• publishing quality performance: making data widely available
• recognising and rewarding quality: ensuring the right incentives are in place
• raising standards: developing stronger clinical leadership
• safeguarding quality: providing reassurance to the public through effective regulation
• staying ahead: supporting innovation in the NHS.

Patient choice and integration

The government committed to transform NHS and adult social care services to enable people to have more choice and control over receiving integrated, high-quality services. The review encouraged greater provision of care in the home, but acknowledged that this may increase the demand for social care services. The report also highlighted the anomaly of having different systems of charging between NHS and social care services.

The next stage review committed to :

• expanding patient choice through the extension of GP practice choice and improved information through NHS Choices
• the introduction of a new right to choice (both of treatment and of providers), supported by a right to access information on service quality in the first NHS constitution
• personalised care plans for those with long-term conditions
• a national pilot programme to test models of personal health budgets (PHBs).

The report was notable for introducing Integrated care organisations (ICOs). ICOs were intended to bring together professionals from health and social care to achieve more personalised, responsive and coordinated care.

The integrated care pilot programme (ICP) was set up to test various models of integrated care. Each pilot site sought to test a different and new approach to integrated working between health and social organisations, to improve outcomes for patients, service users and carers.

The pilots ran for 2 years and were followed by a 3-year evaluation programme.

The evaluation found that, while staff believed the pilots had resulted in process improvements, and that these process improvements had or would lead to care improvements, improvements were not seen in patient experience, nor was there evidence of a general reduction in emergency admissions.

There was, however, a significant net reduction in overall secondary care costs for sites focusing on the case management of elderly people at risk of hospital admission. This was mainly due to reductions in elective admissions and outpatient attendance.

Regulation

The review highlighted the role of the new joint regulator – the Care Quality Commission (CQC).

The report noted that the CQC would have increased enforcement powers, compared with its predecessor regulators. This suggested that the CQC would have a stronger focus on compliance and more flexible powers to deal with those providers not meeting registration requirements.

Darzi also proposed a stronger role for the National Institute for Health and Clinical Excellence (NICE). The review suggested that all patients would receive drugs and treatments approved by NICE, where recommended by clinicians. NICE's role would also be expanded to set and approve more independent, quality standards.

Commissioning

The government committed to reinvigorate practice-based commissioning (PBC) and provide strong support for PBC through incentives for clinicians to be involved in commissioning.

The government stated that it would act to hold PCTs to account for the quality of their support to practice-based commissioners.

The government would introduce 'commissioning for quality and innovation' (CQUIN), a payment incentive for providers, designed to reward quality in tariff payments, as well as activity. Quality indicators such as safety, clinical outcomes and patient experience would be used. The scheme would be an 'overlay' on payment by results.

Regarding the World class commissioning (WCC) programme, launched in December 2007, the report set out that those primary care trusts that had demonstrated they were improving health outcomes would be given greater freedom over the priorities they set and the methods, people and approaches they employed.

Polyclinics

The concept of 'polyclinics' was also proposed in the next stage review. The report outlined plans to open over 150 GP-led health centres that would provide a range of services, such as diagnosis, mental health, sexual health and healthy living services. The review also committed to implementing a wide-ranging programme to support the development of vibrant and successful community health services and a commitment to support staff to set up social enterprises.