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Darzi sets out vision for future of the NHS

Lord Darzi's long-awaited NHS Next Stage Review is out. Here's what it means for GPs.

By Pulse news desk

Lord Darzi's long-awaited NHS Next Stage Review is out. Here's what it means for GPs.

It is, we are told, the review to end all reviews. Described by health secretary Alan Johnson as ‘the most important development in the history of the NHS', the NHS Next Stage Review sets out the Government's blueprint for the future of the health service.

It's been a year in the making. Engagement events were held up and down the country and thousands of clinicians and staff were consulted, but the final report was clearly driven by one man, Lord Ara Darzi.

If not quite a household name, Lord Darzi has become a bogeyman figure in practice staff rooms up and down the country – so unpopular, in fact, that the LMCs conference earlier this month demanded his resignation before representatives had even seen his review.

But what of the report's content? For most GPs there will only be one top line – the MPIG, upon which 90% of practices are financially reliant, is to go. But there is much more, with the report covering everything from practice-based commissioning to reform of NICE to the future of the QOF. Among GPs responding to the review, the only consensus seems to be that there is no consensus.

In truth, it is a curate's egg – some good, some bad. On areas such as NICE reform and clinical leadership, there is a grudging recognition from GP leaders that, just maybe, Darzi has come good. But the removal of the MPIG and unrelenting focus on choice, with practices forced to compete for patients, has been far less well received. As GPC chair Dr Laurence Buckman puts it: ‘That is not the way general practice works.'

Some would argue that what is most significant is what was left out. Presenting his review to the House of Lords, Lord Darzi said: ‘I have not mentioned my favourite word, polyclinics.' The massively controversial national rollout of GP-led health centres, first announced in Lord Darzi's interim report in October, is of course going ahead. But the resulting patient backlash, which culminated in the BMA's 1.2-million signature petition, seems to have made ministers think twice about a further rollout dictated from Whitehall.

Otherwise, though, the NHS Next Stage Review and accompanying Primary and Community Care Strategy contain a wealth of detail on the future of general practice. Sit back, relax, and read what you will be doing over the next 10 years…


For the past year it's been general practice's worst kept secret, and you read it on Pulse's front page earlier this month. But now it's official: MPIG is toast.

Or, as the report puts it: ‘At present, most GP practices receive historic income guarantees that do not necessarily bear relation to the size or needs of the patient population they now serve, or the number of patients they see.

‘We will work with GP representatives to manage the phase out of these protected income payments, so more resources can go into providing fair payments based on the needs of the local population.'

Launching the review, health secretary Alan Johnson insisted the MPIG ‘militates against people accessing choice' and is a ‘barrier to tackling health inequalities'.

Fair funding, sounds, well, fair enough - but GPs have real cause for concern. Almost 90% of practices are reliant on the MPIG and the GPC warns its abolition could send one in 10 to the wall.

Everything now depends on timing, and the phase-out model GPC negotiators thrash out with NHS Employers. Earlier this month Dr James Kingsland, chair of the National Association of Primary Care and an adviser to Lord Darzi, suggested ministers would look to remove the MPIG within three years - GPC chair Dr Laurence Buckman believes 15 years would be more realistic. Negotiations, it's fair to say, will be intense.

And more questions remain over the global sum formula. The formula review group's report last year was kicked firmly by ministers into the long grass and hasn't been seen since – but some overall adjustment of the formula may well form part of any final solution.


Choice has always been a Government buzzword, but now it is being applied to general practice as never before.

Under the planned NHS Constitution, patients will be given a legal right to choose any GP practice and request any GP within that practice, unless there are ‘reasonable grounds' to refuse.

And GPs will be expected to step up efforts to compete for patients in order to maximise the opportunities for choice. Health minister Ben Bradshaw has made clear he has had enough of ‘gentlemen's agreements' under which he says GPs avoid going head to head.

Patients already have the right to be referred to any hospital in the country and the Government is keen to do the same in primary care, citing narrow practice boundaries and closed or ‘open but full' practice' lists as barriers to patient choice.

NHS Choices will be expanded to include comparative information about the range of services practices provide, opening hours and performance against key quality indicators. Patients will also be able to register electronically with a practice through the site and view both positive and negative comments left by fellow patients.


To put ‘quality' at the heart of a healthcare review might sound rather obvious, but it has not stopped Lord Darzi.

It will be assessed, reported and scrutinised in more ways than ever before.

The most obvious impact on GPs will be with the requirement for practices to start publishing annual ‘Quality Accounts' by April 2010.

All healthcare providers working for the NHS will be required to produce these, just as they do financial accounts, with details of each one of their services, and statements on safety, experience and outcomes.

A new set of quality metrics will be developed to allow services at different providers to be compared. The first set of indicators will be in place by December, and while initially they will focus on acute services, community services will follow shortly.

The Government is also supporting an RCGP-led practice accreditation scheme and wants to collect a raft of new information through surveying patients.

Perhaps the key move towards quality comes with a shift towards funding patient outcomes as well as patient volumes. Money freed up through reducing the Payment By Results tariff uplift from next year will be used to reward outcomes by 2010 at the latest.


Lord Darzi is pledging to kick-start a practice-based-commissioning scheme which has well and truly stalled on the grid. The review admits PBC has failed, but vows to ‘redefine and reinvigorate' the flagging initiative.

It promises incentives to encourage a broader range of clinicians to get involved, and pledges greater scrutiny on PCTs to ensure commissioning groups are supported.

All of this, of course, we've heard before, although more radical are plans to pilot new integrated care organisations. These will be commissioned by PCTs to provide healthcare outcomes, and will see GPs working more closely with hospitals and community services in order to hit targets.

Social enterprises will also get a growing role in the new NHS, with nurses as potential healthcare leaders of the future.

PCT staff are to be given a ‘right to request' social enterprises are set up to deliver services – potentially meaning nurse-led companies could go head-to-head with GP practices to compete for patient services.


The QOF has endured all sorts of tucks and tweaks, but this time it is in line for a major overhaul. Lord Darzi's vision will shift the emphasis from incentives gained for processes and administration towards those earned from outcomes. And GP payment could increasing rest on what patients say about their healthcare, via the patient survey.

The process of arriving at new versions of the QOF is set to be made more streamlined, and will include a more ‘independent and transparent process for developing and reviewing indicators'. NICE is set to have a much larger role, with an independent panel likely to review and develop new indicators.

Not for the first time, the Government has mooted the idea of local versions of the QOF, with the potential for a national menu of QOF indicators, from which PCTs could choose those that best suit their local needs.


The review treads now familiar ground by warning that the NHS is more of an illness service than a health service. ‘Currently the incentives for general practice focus largely on the effective management of long-term conditions rather than seeking to prevent those conditions in the first place,' it says.

So expect less emphasis on cure and far more on the Department of Health's favourite word: prevention. The Government's resources are to be focused on six key goals: tackling obesity, reducing alcohol harm, treating drug addiction, reducing smoking rates, improving sexual health and improving mental health – all areas in which GPs could potentially have a role.

Funding will be provided for GPs to tackle obesity in primary care, as well as alcohol-related ill health and as of next year, provision of psychological therapies and musculoskeletal services, as part of the ‘Fit to Work' scheme.


Meanwhile those patients with long-term conditions will be given even greater control over their care under Darzi's new vision for a more personalised healthcare system.

Darzi plans to introduce personal budgets and care plans nationwide under the banner of patient choice, to ‘empower' individual patients and enable them to ‘use their personal knowledge, time and energy in solving their own health problems'.

Within two years, all 15 million people living with long-term conditions in the UK will be offered a personalised care plan. GPs are likely to take a key role.

Patients will also be offered personal health budgets in a national pilot from early 2009.


Surgeon-turned-politico Lord Darzi is the ultimate example of a doctor who has turned his hand to NHS management. But the plan is for many more doctors to be trained up as local leaders of the NHS.

A series of practical measures to boost clinical leadership are proposed. Undergraduate and postgraduate curricula for medical and nursing students will be developed to reflect the importance of leadership skills. A network of SHA medical directors and SHA clinical advisory groups will be appointed to work closely with PEC chairs and an NHS leadership council chaired by the NHS chief executive David Nicholson will be established.


The NICE appraisal process for new drugs is to be dramatically accelerated under Government plans to reduce the current ‘postcode lottery' in access to treatments.

The institute has often been criticised for taking too long to issue guidance on new treatments, with decisions on access to treatment often left to individual PCTs.

This will change under proposals in the NHS Next Stage Review to force NICE to issue the majority of its advice within a few months of a new drug being launched..

The report also says patients' rights to treatments will be enshrined in a new NHS Constitution. Patients will have the legal right to any treatment approved by NICE for use on the NHS and PCTs will be legally bound to explain to patients the rationale behind not funding treatments in their areas.

Quite how the NHS will pay for what could turn out to be a dramatic widening in access to treatment is less clear – But then that's a theme that sweeps right through the whole of health policy in just 92 pages.

Plenty of big ideas - just rather lacking on the small print.

Best and worst of the Next Stage Review - our experts give their verdict

Dr Laurence Buckman, GPC chair
+ 'The emphasis on quality of care being clinically driven. General practice has led the way with the Quality and Outcomes Framework which is making life immeasurably better for thousands of patients.'
- 'Despite the fine words the effect of the plans for polyclinics and health centres.'

Professor Martin Roland, professor of primary care, University of Manchester
+ 'I liked the idea of personalised care plans. Continuity of care has been eroded over the last few years, so having one named person – not necessarily a GP – responsible for a person's care is a good idea.'
- 'In many ways there's not an awful lot to disagree with. How things are implemented will be very important. The Government has listened to the profession in terms of moderating some of its original ideas.'

Niall Dickson, chief executive of the King's Fund
+ 'There is the opportunity for doctors, nurses and other professionals to help shape services that are more tailored to local needs.'
- 'There are no estimates of how much any of the new proposals will cost and no indication of how far and how fast the government expects the NHS as a whole to change over the next five or ten years.'

Professor Allyson Pollock, professor of public health policy, University of Edinburgh
+ Professor Pollock couldn't find anything food to say about the review.
- 'It's a duplicitous report because it has not discussed at any point the Government's main strategy – the privatisation of clinical services and their sale to the highest bidder. It's a document for the destruction of everything that the NHS has stood for.'


What is the Next Stage Review?
Surgeon-turned-health minister Lord Darzi was asked last summer to undertake a once-in-a-generation review of the NHS, with an unprecendented remit stretching from cardiovascular screening to workforce planning to GP finance.
His interim report published in October laid out plans for a network of polyclinics, with one in every PCT.

How much of it focused on primary care?
A large chunk. Lord Darzi may be a surgeon, but general practice was a key focus of the review, and a primary and community care strategy, also published last week, explored the main themes in detail.

And how will it affect GPs?
The end of MPIG, cardiovascular screening, a revamp of PBC and practice ratings - the review will touch most areas of GPs' work.

What happens next?
The NHS Operating Framework to be published this October will set out the 'enabling system' to deliver the goals, and PCTs must publish a five-year plan by next spring. The Government will also give two years' worth of funds to PCTs later this year to allow them to plan ahead.

Primary care took a central position in Lord Darzi's review Lord Ara Darzi

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