Lord Darzi on why clinicians must be in charge of reform
With the first anniversary of the publication of NHS Next stage Review coming up this month, Richard Staines talks to the architect of the plan, health minister Lord Darzi, on progress so far and priorities for the future
‘Some of the feedback I have from front-line staff is that they have found the next stage review liberating. This is the sense that they feel they have greater permission than ever to stand up for the quality of care, to challenge practice and lead improvements,’ said health minister Lord Darzi in an interview with Nursing Times last week.
It has been a year since surgeon and politician Lord Darzi published his NHS Next Stage Review, a document setting out the future development of the health service. It called for a greater focus on improving the quality of care that put patients at the centre of decision-making.
The NHS Next Stage Review built on The NHS Plan, published in 2000, which outlined the government’s over-arching health policy for its first and second terms in office.
Although the goals of the next stage review are broadly similar to those of The NHS Plan, such as reducing regional health inequalities, the review differs in several key ways.
While the NHS Plan set out targets that would be enforced centrally, such as the 18-week waiting limit, and attempted to bring about change with huge government investment, Lord Darzi’s plan calls on NHS staff to be the agents of change and empowers them to improve services through innovation.
There has been some progress over the past 12 months on tthe move away from the old-fashioned, top-down NHS management approach towards allowing clinicians to take more control at a local level.
‘I don’t see myself here instructing any nurse or any doctor in saying that these are the measures you need to use to deliver your care’
Just last month, as reported by Nursing Times, the government published a list of 200 quality indicators, commonly known as metrics, that could be used across the NHS.
In line with the review’s clinical empowerment agenda but what perhaps came as a surprise to many in the nursing profession was that the use of the performance indicators would not be mandatory and individual organisations could choose which ones best applied to them.
Lord Darzi said the metrics were not mandatory targets, like those set out in the NHS Plan, because he wanted clinicians to take ownership and decide which metrics were most relevant to use themselves.
‘I don’t see myself here instructing any nurse or any doctor in saying that these are the measures you need to use to deliver your care,’ he said.
Drawing on his dual role as a surgeon and minister, he said: ‘I do wear two hats, as you know, and I would be very irritated on a Thursday if someone sent me a metric that I needed to measure. I know exactly what I need to measure because I am the person delivering the care – and every nurse should have that.’
Examples of the new metrics include measuring emergency readmissions to hospital within 28 days of discharge following a stroke, or measuring call to needle time for ST-elevation myocardial infarction patients.
Lord Darzi said that the chief nursing officer for England, Christine Beasley, and her team were also working on a set of indicators specifically for nurses and midwives. She has set up an advisory board to advise on the ‘shape and direction’ of the indicators.
Returning to the subject of local change, Lord Darzi said another useful way for nurses to improve their own services could be for them to produce their own lists of ‘never events’ – events that are serious and largely preventable.
The Next Stage Review proposed that ‘never events’ in England should be identified and monitored.
Progress has already occurred on this front. The National Patient Safety Agency published a list of national never events in November last year. There are eight, including wrong-site surgery, instruments being retained after an operation and chemotherapy administered via the wrong route.
PCTs can choose to monitor and tackle different types of event on the list, which will eventually be included in commissioning contracts.
Lord Darzi also urged nurses to consider creating their own list of preventable never events for own area of work.
‘If you come to my firm, patients are first seen by the specialist nurse’
For example, nurses might want to define a never event based around nutritional standards and use that to improve care quality, Lord Darzi added.
‘If you have an issue about nutrition in your ward, you need to identify what the problem is, you start to identify what the nutritional standards should be, you start identifying measures that you need to measure against the standards then you say this is the policy that we are going to adopt,’ he said.
Another Lord Darzi buzzword is ‘teamwork’ and he is keen to point out the contribution nurses make to his surgical team.
‘If you come to my firm, patients are first seen by the specialist nurse,’ he said. ‘They take pictures of them, examine them, get diagnostics organised – she might actually make a diagnosis.’
However, he sees NHS teamwork as yet another area ripe for measurement. ‘We also need to identify metrics that measure the teamwork of clinical team,’ he said. ‘Because I know that I cannot deliver my practice without the teamwork of my nursing colleagues. I am sure the nursing colleagues will tell me the same – they cannot deliver without the contribution I make to that team.’
In particular, patient experience surveys, conducted every year by the Care Quality Commission and the Picker Institute, could well point to how well a clinical team is performing, Lord Darzi suggested.
‘[This will] capture the patient’s experience of the nurse, the doctor, with the occupational therapist,’ he said.
However, while work appears to be progressing well in the move towards more a measurable health service that should lead to a better quality of care, Lord Darzi was less happy with progress on other aims of the review.
At the top of his to-do list is the integration of health and social care services, where he says much work is still to be do be done. Health and social services are not working together as they should and, as a result, care is suffering, he said.
‘There is still too much separation between organisations which present hurdles for patients to negotiate rather than providing seamless services, in which there is no difference for the patient between acute, primary care or social care provider,’ said Lord Darzi.
Another aim of the Next Stage Review that is seemingly yet to take off is the push to make more nurses entrepreneurs – within or outside the health service.
In particular, the review talked of nurses and other staff creating social enterprise schemes that would be independent of the health service but commissioned by it to provide services.
In theory, now that the Treasury has agreed that nurses could keep their NHS pension schemes if they transferred to social enterprises, there would appear to be little to stop nurses starting their own organisations to provide services to the NHS.
The downside is that – as with any other business – they can fail. An economic recession is unlikely to be a popular time to start a business outside the safety of the NHS.
‘Just believe in what you can do and get out and do it’
Despite this, Lord Darzi has faith that nurses can and will become health entrepreneurs and improve the quality of services. ‘Most nurses have all the competencies to manage patients when they are ill – now compare that the risk of running a business,’ he said.
Unlike nursing, running a business is not life or death, said Lord Darzi. Therefore nurses should easily cope with the challenges of being in charge of an organisation.
‘If you have a complex sick patient, you have the competencies. Just believe in what you can do and get out and do it,’ he said.
Lord Darzi said he saw social enterprise schemes as vital to the reform of community services – and community services are central to the Next Stage Review’s vision of an NHS that is more responsive to the needs of patients.
The government document Our Vision for Primary and Community Care – what it means for Nurses, Midwives, Health Visitors and Allied Health Professionals was published in July 2008, one month after the main review document.
Lord Darzi said he saw this document as one of the main achievements of the review process to date. It established the Transforming Community Services programme (TCS), which has involved more than 1,000 nurses and allied health professionals.
Part of this work will result in a set of ‘transformational guides’ in six service areas that are intended to help nurses improve the quality of community services – inevitably through the measurement of care against indicators.
The six chosen service areas are: health and well-being; children and families; people with long-term conditions; rehabilitation; providing hospital care close to home; and end-of-life care.
‘[These will] enable nurses and allied health professionals to design, deliver and lead the transformation and a quality framework that over time will build indicators so that the quality of community services can be measured,’ said Lord Darzi.
One of the goals is to take advantage of technology, such as physiological sensors and the internet, to move patients away from hospital settings back into their homes.
‘When I started training, patients with cardiac failure were in an intensive care unit or a coronary care unit because they had heart failure,’ he said. ‘They are now cared for treated at home by community nurses.’
As evidence for progress in this area, Lord Darzi highlighted the use of physiological sensors, which measure pulse and blood oxygenation levels. Information from these can be transmitted to a community nurse, who can then instigate an early treatment.
Nationally, a £1.5m TCS innovation and leadership fund has been set up to enable nurses and others to test creative ideas.
Additionally, there is much to be done in taking forward the nurse education reforms outlined in another subsidiary document of the Next Stage Review, called A High Quality Workforce. This document included a commitment to the move to an all-graduate entry level profession.
Lord Darzi welcomed the work already produced by the NMC’s review of pre-qualification nurse education, which will phase out nursing diplomas by 2013–2014. The first phase of this review was carried out from November 2007 to February 2008. The second phase of the review is under way.
‘There is still a lot of work to be done collaboratively between the NMC, DH and universities to achieve this [all-graduate entry level],’ he said, adding that existing nurses would not need to gain degrees.
‘Only new registrants will be required to have degrees. There is no requirement for current nurses to get degrees to stay on the register,’ he said.
‘The current nursing workforce will continue to have valid registrations and play a fantastically valuable part in providing intelligent care with skill and compassion.’
Despite Lord Darzi’s positive words, the NHS is once gain facing challenges that he could not have accounted for when drawing up the next stage review – namely an economic recession and political turmoil.
The effects of the recession are largely yet to affect the public sector but, when they do, could be severe. Last week, the NHS Confederation predicted spending cuts of up to £15bn in the NHS over the next 10 years, which could radically change the face of the health service.
Lord Darzi said he was not concerned that his programme of reforms would be threatened by internal changes at the Department of Health earlier this month. Alan Johnson, who was in charge of the Department of Health when the review was published, is no longer health secretary.
‘The implementation of the NHS Next Stage Review is heavily dependent on clinicians leading local change’
He was – perhaps unsurprisingly – positive about his new boss, Andy Burnham, who was appointed as health secretary in Prime Minister Gordon Brown’s cabinet reshuffle.
‘Andy is absolutely brilliant and he has worked in health before – he was the health minister here. He is very much engaged in the health reforms and sees that the Next Stage Review is the continuum of the many reforms that he has been involved with in the past,’ Lord Darzi said.
Whatever the political or economic challenges, Lord Darzi said that he believed that the success or failure of his reform plans lay squarely with his clinical colleagues working on the front line.
He said: ‘The implementation of the NHS Next Stage Review is heavily dependent on clinicians leading local change. They are best placed to work with stakeholders including patients to improve services continuously.’
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