What do "Best Practice Tariffs, "Personalised Care Plans" “Quality Accounts” and "the NHS Constitution" all have in common? Answer: they are all recommendations proposed by Lord Darzi in "High Quality Care for All", the highly anticipated Final Report of the NHS Next Stage Review, which was published on 30 June 2008. It follows the publication of the Interim Report in October 2007 which championed the introduction of GP led health centres for all Primary Care Trusts (“PCTs”) and over 100 new GP practices for those PCTs with the poorest primary care provision. A framework for the implementation of these proposals was initiated under the “Equitable Access to Primary Care Programme” (click here for details). So, what are the Final Report's recommendations, what do they say about the future direction of the NHS and are the proposals as controversial as anticipated?
There are four broad themes in the Final Report; achieving quality patient care; making quality care integral to the NHS; empowering and supporting NHS staff to deliver quality care; and developing an NHS constitution. In Darzi's words, the "beating heart" of the Final Report is to drive quality in the NHS. Whilst the last ten years have seen a dramatic increase in the capacity of the NHS, there are still significant variations in the quality of care provided. Patient satisfaction will be at the centre of this drive to improve quality.
ACHIEVING QUALITY PATIENT CARE
As part of the objective to empower patients and give them more influence and control over the care they receive, the Final Report reinforces the patient choice principle in a number of ways. This includes support for a legal right for all patients to choose their place of care, a reduction in the number of "closed" practice lists to provide greater choice of GP, the phasing out of protected income payments for GP practices and measures to provide more convenient and quicker access to diagnostics.
The Interim Report encourages the promotion of good health within the community. All PCTs, in partnership with local authorities, will be required to introduce comprehensive services to prevent ill health, particularly in the areas of obesity, alcoholism, drug addiction, smoking, sexual health and mental health. The importance of the employer’s role in promoting good health is also recognised. To encourage investment in preventative health services in the workplace, there is a positive drive to ensure that 25% of FTSE 100 companies report on employee health and wellbeing at board level by 2011.
INTEGRATING AND DELIVERING QUALITY PATIENT CARE
The Final Report contains proposals to integrate quality care at all levels of the NHS and to empower Trusts and staff to deliver quality care. The recommendations include:
- Hospital funding to be linked to patient satisfaction and the effectiveness of treatment.
- “Best Practice Tariffs” (rather than tariffs based on average cost) to be introduced and, initially for 4 high-volume areas where there are major unexplained variances in quality of practice.
- Oversight of quality to be undertaken by a national board with comparison against international standards.
- Stronger focus on compliance and enforcement by the Care Quality Commission, the new health and adult social care regulator, particularly in relation to failures in infection control and adverse incidents.
- All healthcare providers working within the NHS to publish “Quality Accounts” which will be made available on the “NHS Choices” website.
- “Health and Innovation Clusters” to be established based on partnering between the NHS, universities and industry.
- Stronger support for practice based commissioning and the piloting of new “integrated care organisations” designed to encourage partnerships between primary, secondary and social care across a range of organisations, including community services, hospitals and local authorities.
- Acceleration in the number of NHS Trusts achieving Foundation Trust status.
- More autonomy for community services through the establishment of community foundation trusts, care trusts and social enterprises, with an emphasis on using community settings for some services traditionally provided in hospitals.
THE NHS CONSTITUTION
The Final Report supports the case for an NHS Constitution to enshrine the guiding principles of the NHS and set out the legal rights of patients and commitments to NHS staff. All NHS bodies and private/third sector providers would have to take account of the Constitution when making decisions. The Constitution would be updated every 10 years and be supported by a "Handbook to the NHS Constitution", revised every 3 years. A consultation on the draft Constitution and how it should be put into practice was launched with the Final Report and is open until 17 October 2008.
PRIMARY AND COMMUNITY CARE
A separate Department of Health report on primary and community care was published on 3 July 2008 to build on some of the key messages in the Interim Report. This includes extending patient choice across primary and community care, encouraging new models of integrated care and promoting stronger partnership working between the NHS, local government, independent sector providers and the third sector. Like the Interim Report, it is not prescriptive about how proposals should be implemented and while it supports more integrated service provision, it leaves the delivery model open – a “one stop shop” may be the answer for some communities or for others, a network of services may be better. More innovative estates strategies could also be on the cards, using private finance or arms-length property companies.
To encourage a wider debate on the integration of health and social care, a Minister-chaired group is to be set up to work with stakeholders to identify how government can provide more support for the development of integrated delivery models, including tackling policy change and financial or cultural barriers to new ways of working.
TIMELINE FOR IMPLEMENTATION
The key dates for implementation of the recommendations of the Final Report are:
- Later this year – PCT financial allocations for the next two years will be announced.
- October 2008 – An "NHS Operating Framework" will be published, setting out the enabling system for delivery of the recommendations.
- Spring 2009 – Each PCT will publish its own strategy, setting out a local five year plan for improving the health of its population.
- From 2010 – Funding to hospitals will take account of patient satisfaction rates and "Best Practice Tariffs" will be introduced for some key areas.
The Final Report contains ambitious proposals for improving the quality of care provided by the NHS. The proposals pose bold challenges for NHS bodies and signal opportunities for involvement by the independent sector in achieving Darzi’s objectives. However, in some respects, the Final Report is aspirational and lacking in concrete proposals. It is difficult to predict at this stage precisely how the proposals will be implemented. No doubt the devil will be in the detail. The NHS Operating Framework (to be published in October) should define the implementation plan in more practical terms, but it remains to be seen whether PCT budget allocations will enable the Final Report's ambitions to be realised.
Darzi has shaped a direction for the future of the NHS but has not specified a route map for the achievement of the objectives set. He has left this for the local NHS and its partners to determine based on individual community needs. While the Interim Report ignores the controversy over “polyclinics”, it acknowledges that multi-service health centres may well be suitable for some communities. This is reflective of a wider theme running through the Interim Report – change will be driven at local level. The market will, therefore, have to wait for the publication of the various PCT strategic plans over the course of the next year before understanding in real terms what is next for the NHS and what role the independent sector might play.