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NHS Next Stage Review

Professor the Lord Darzi KBEParliamentary Under-Secretary of State

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Why do we need a Review?…• Objectively the NHS is better than ever

• Subjectively there has been confusion and frustration in the NHS, especially among NHS staff – why?

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wJourney so far

• Ten years ago the NHS was in relatively poor health:

– Investment had varied hampering planning– Access was poorer, with long waiting times– Capacity problems led to an annual winter crisis

• My own experience illustrates the improvements since then:

– More staff on the team– Shorter waits for patients needing operations– Higher quality care that is more personalised

• Across the country:

– Tens of thousands more doctors, nurses and others– Hundreds of new or refurbished facilities and lots of new kit– Care still provided according to clinical need not ability to pay

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w… based on a fresh approach to change

• Reactive in nature• Designed to meet Targets• Clinicians often not engaged

in process• Clinical leadership not

essential• Targets become the goal• Difficult to sustain clinical

improvement over time & across organisation

• Proactive in nature• Evidence-based foundation• Clinicians actively engaged

in process• Clinical leadership critical to

success• Best and safest care is the

goal, indicators as markers of success

• Sustainable improvement over time and across organisation

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wClinical Case for Change

• Major inequalities in health and wellbeing across the

country

• Variation in care across the country

• NHS lags behind other countries on treatment outcomes

• Care could be more convenient and easier to access for

many

• Care needs to keep pace with the expectations of citizens

• Disease patterns evolve & the population is ageing

• New technology and treatments

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6

Major inequalities in people’s health

• Life expectancy varies across the country

• Lowest life expectancies are concentrated in parts of London, Midlands, Yorkshire, North West and North East

• Partly due to unhealthy behaviours and societal factors, but…

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wVariation in care across the country

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Fewer GPs and worse care in areas with greatest need(Areas with the fewest GPs have poorer quality and outcome (QOF) scores)

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wDisease patterns arechanging, so is the population

• People with long term conditions – e.g. diabetes, asthma, heart disease - use health services more – 58% of all GP appointments, 77% of inpatient bed days

• Population is ageing – by 2029 there will be 50% more 75 to 89 year olds

• Long term conditions are set to increase as the population ages

• And currently only a small a proportion of patients receive optimal long term conditions care

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w9

NHS Next Stage Review - process

Clinical Pathway groups in each SHA:

• Maternity & New-Born Care• Staying Healthy• Children’s Health Care• Acute Care• Long-Term Care• Planned Care• Mental-Health Care• End-Of-Life Care

21st Century NHS

Local visions for health and healthcare that meet local circumstances and

needs, supported by national principles, minimum standards and

enablers

National Themes to include:

• Quality and Safety • Clinical leadership• Education & training• Innovation • NHS constitution• Local accountability

Engagement of patients, staff and public

Communications

Local National

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wStaying healthy

Population-level interventions

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wAcute pathway

A telephone triage service is required to support services

Ambulance

Paramedic

Health and urgent care centres

Appointment withmost relevant team- social care, LTC, GP

Advice andinformation

999 for emergencies

Single number for all urgent case services

Access to healthcare records

Up-to-date information on all local services

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wPlanned care

DH estimates that much outpatient activity could be conducted in the local care setting

64% of total outpatients could be removed or devolved from hospital outpatients, leaving only 36% in the traditional outpatients setting

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wLong-term conditions

Acute Hospital

• Emergency care

• Inpatient care

• Specialist outpatients

• Specialist diagnostics

Increased direct access to diagnostics,e.g. MRI

Routine diagnostics

Shift 100% of x-ray and ultrasound

Outreach outpatients

Specialists for long-term conditions:

• doctor

• nurse

• therapist

Outpatient appointments(new and follow-up)

Shift ~60%

NHS next stage review will put community-based care at the centre

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wLong-term conditions

Create a web of care with the individual at the centre

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wDelivery models

Health Centres - GP, community and some currently hospital-based care in the local setting

General practice services

Most outpatient appointments (including antenatal and postnatal care)

Community services

Minorprocedures

Interactive health information services including healthy living classes

Other health professionals e.g. optician, dentist

Urgent care

Proactive management of long-term conditions

Diagnostics – point-of-care pathology and radiology

Pharmacy

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wDirection of travel

Organisational Unit

Service Focus

Mechanismof

Delivery

IndividualGPs

IndividualGPs

PCTs +/-?Integrated Trusts (NB

Kaiser)

PCTs +/-?Integrated Trusts (NB

Kaiser)

10 HealthServices

nGMS / CHS

10 HealthServices

nGMS / CHS

Larger GP Units

Larger GP Units

1965 2005 1998 1990

The RedBook

The RedBook

Populations &Communities

of InterestChoice

Populations &Communities

of InterestChoice

PracticePopulations

PracticePopulations

SpecificTarget Groups>75 years etc

SpecificTarget Groups>75 years etc

IndividualPatients

IndividualPatients

Various NHS and PrivateProviders

Various NHS and PrivateProviders

PracticeContracts

(PMS)

PracticeContracts

(PMS)

GP Commissg

GP Fundholdg

TPP/Multifund

GP Commissg

GP Fundholdg

TPP/Multifund

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wCurrent IS involvement

Through Independent Sector partnerships, the following services are already being delivered:

• 23 independent sector treatment centres (Wave 1)

• 10 walk-in centres (6 with a commuter focus)

• Mobile ophthalmology services

• Mobile MRI scanning services

• Chlamydia screening services

• 5 ISTC schemes are operational (Phase 2)

Huge opportunities for capable providers to deliver these services

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In the run up to April 2008– Roll out choice video on Life Channel in more than 2,000 surgeries – Roll out a national training programme for librarians in all 3,088 public

and mobile libraries and in UK Online centres– Expand our work with the third sector (Princess Royal Trust for Carers,

Arthritis Care and Age Concern) and other voluntary sector groups to raise awareness

Since January 2006 - Patients have a choice of 4 or more local hospitals, and 139 other hospitals through the Extended Choice NetworkFrom April 2008 - Patients able to chose services from any hospital nationally, which has the capacity to treat them and meets NHS standards

The NHS Choices information service creating better access to information about health services (Hospitals and GP Practices)

Patient Choice

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The patient’s chosen providerRight therapy

Right timeWhen needed

High quality and safe

System Management is…

“The actions and behaviours to make a local health system the best it can be”

Tasks of system managers:

• Building the system• Ensuring strategic

coherence• Maintaining system

effectiveness

Values of system management:

• transparency, • objectivity, • proportionality, • non-discrimination, • subsidiarity, • consistency, • no double jeopardy

• Commissioning• Procurement & Contracting• Choice offer• Promotion• Payment• Failure, Support and Intervention• Transactions• Market management• Market development

Technical aspects:

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wPrinciples and rules for co-operation and competition

Commissioning, competition and choice are powerful levers…..

…..to drive up service quality, deliver better value and reduce inequalities

Examples of key principles

• Commissioners should commission services from providers who are best placed to deliver the needs of their populations

• Commissioning and procurement should be transparent and non-discriminatory• Commissioners and providers should foster patient choice and ensure that patients

have accurate and reliable information to exercise more choice and control over their healthcare

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wFESC (Framework for Procuring External Support for Commissioners)

21

An additional tool for the PCT toolbox

PCT Commissioning

Function

Private Sector Support

Ad hoc local procurement (full process)

Other national

procurements

Local solution

from FESC

Public sector/NHS

Support

Collaborative procurement

Commissioning business services

Skills pooling

SHA-led services

Joint arrangements

with local authority

Internal Support

External consultancy

(for training or general support)

Recruitment of specialist staff

BUY SHARE

LEARN

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“It is not the strongest of the

species that survives,

not the most intelligent,

but the one most responsive to change.”

Charles Darwin

NHS into the 21st century