Intended for healthcare professionals


Darzi review: Reward hospitals for improving quality, Lord Darzi says

BMJ 2008; 337 doi: (Published 01 July 2008) Cite this as: BMJ 2008;337:a642
  1. Rebecca Coombes
  1. 1London

    Hospitals will be required to publish a range of data on outcomes, from surgeons’ death rates and infection levels to patients’ ratings of whether staff were compassionate, under changes included in the final report of Ara Darzi’s review of the NHS this week. These data would in part affect the amount of funding given to healthcare providers.

    The long awaited report from the health minister Lord Darzi did not set any new national targets or herald any substantial reorganisation for the NHS but instead emphasised the need to improve quality of care after a decade of investment in services. Lord Darzi said that providers would have to publish quality indictors so that patients could choose where, when, and how to be treated in the NHS.

    For the first time, patients’ own detailed views on their treatment will be collected and published, alongside more objective measures of safety and clinical outcomes. Data will be available on NHS websites but will also be displayed in hospitals and general practices—for example, information on length of stay and how soon patients are seen.

    Lord Darzi said, “The patient experience is the most powerful lever here and will be used for service improvement. The whole report is about quality—it’s what energises staff in the NHS. We have done the investment, increased the number of doctors and nurses; we are getting rid of waiting lists [and] now want to improve quality of care.”

    Watch the BMJ interview with health minister Lord Darzi

    The health secretary, Alan Johnson, said that the report was about “more clout to patients, more say to patients.”

    In addition to the payment by results system, funding to hospitals will also depend on quality of care as well as volume. About £7m-9m (€9m-11m; $14-18m) of an average district general hospital’s annual £250m budget will depend on delivering better outcomes, said Mr Johnson. There will also be bonus money for high performing clinical teams. NHS organisations will have to publish “quality accounts” alongside annual financial accounts.

    Lord Darzi announced the draft of a new legal NHS constitution, which will reinforce patients’ right to choose who treats them and where and what type of treatment. For example, Mr Johnson said that some patients wanted the power to avoid invasive surgery and opt for a keyhole procedure.

    However, it emerged that this was not an absolute right. Patients could choose a general practice and GP, but little could be done if that practice’s list was full. Similarly, a patient could express a preference for a certain consultant or surgeon, but the choice would not be guaranteed. Furthermore 5000 patients with complex health problems are to pilot personalised budgets.

    Lord Darzi’s final report was not prescriptive about how services could be reformed, although it said that reorganisations of services—for example, setting up specialists centres for stroke care—must be locally driven. And the report said little new on polyclinics, but a more detailed report on primary care is to be published later this week.

    Lord Darzi referred to “change fatigue” among NHS staff. “I understand that NHS staff are tired of upheaval when change is driven top down. It is for this reason I chose to make this review primarily local, led by clinicians.”

    There was general relief about the lack of prescription in Lord Darzi’s report although concern about a lack of detail.

    The BMA said it was pleased that the government has stated its intention to move away from “target driven” health policies, but it was concerned about how data on quality would be collected. Hamish Meldrum, the chairman of BMA Council, said, “There is still a long way to go in having access to accurate, reliable, and meaningful data that enables patients, working with their doctors, to make fully informed choices about their treatment.”

    This was a view echoed by the Healthcare Commission. The chairman, Ian Kennedy, said, “It’s important to recognise that it is not easy to define outcomes when you move from surgery to medical care.

    “For many areas of care—for example, mental health services, elderly care, people with long term conditions, children with complex needs, people with learning disabilities—there is a huge and important task in getting better information on the outcomes being achieved in helping people live healthy and independent lives.”

    Niall Dickson, chief executive of the King’s Fund, said, “The good news is that there is no top down reorganisation or any dramatic change in direction. Instead the report is a sensible set of measures to improve quality and equity and a clear signal that responsibility for shaping and leading health services lies with staff at local level.”

    But it was still too vague, he added. “There are no estimates of how much all this will cost and no indication of just how different the government expects the quality of health services to be in five or 10 years’ time.”

    The NHS Confederation said that the Department of Health must resist “the temptation to prescribe nationally. The proposals appear to be highly permissive and could make a shift in the NHS towards local control if embedded.”

    The report set out ways that the government planned to widen choice in primary care, from enabling NHS staff, such as nurses, to set up “social enterprises” to provide publicly funded health services independently but remain in the NHS pension scheme. Further details will be announced in October.


    Cite this as: BMJ 2008;337:a642