Comment / Time will tell

HFMA chairman Chris Calkin says managers will need to exhibit substantial leadership over a sustained period to implement Lord Darzi’s Next Stage Review proposals

Managers will need to exhibit leadership over a sustained period to drive through Lord Darzi’s Next Stage Review proposals

Lord Darzi’s much awaited review, published at the beginning of this summer, sparked little interest outside the NHS. Even the health minister’s own blog stimulated only a handful of comments. The majority suggest the review broke little new ground.

Most interest was focused on the objective to push services and decision making closer to the patient and involve clinicians. This has been a long held objective for the government, the commentators suggest. So why has it not happened?

Is this a reasonable complaint? As far back as the 1974 reorganisation, the Grey book set about moving decisions from the regional health boards to areas and districts. And Sir Roy Griffiths, in his early 1980s report on NHS management, promoted greater involvement of clinicians. Much of government policy in this area has followed this direction.

So why in the 21st century is this still an issue? Foundation trusts have public and staff membership. And service line management and practice-based commissioning put clinicians at the heart of decision-making. There may be an argument about the pace of change, but surely the policy direction is clear?

However, it is unarguable that Lord Darzi’s proposed changes will need a committed and sustained drive. Consider the former Care in the Community initiative to move mental health services out of Victorian institutions into more appropriate community settings. This was not delivered overnight and, I suspect, has probably not been totally delivered yet. But the Victorian mental health hospital has in the main disappeared. The point is: it took many years. And Darzi, with arguably a more ambitious agenda, will be the same, requiring a major response from the service. And that is not always straightforward.

For instance, I was staggered to discover that only 50% of primary care trusts have LIFT schemes, despite this being key to creating facilities to enable activity to be moved out of hospital settings. To stimulate greater take-up, the Department of Health has introduced Express LIFT and we will have to wait to see if this creates the necessary interest in developing services.

And just as big a battle as getting the service to respond is getting the public to embrace the changes. In a recent MORI poll, the public still identified health services with hospitals and few understood the role of PCTs. Unfortunately there is no equivalent of Holby City for PCTs.

Lord Darzi’s approach has engaged with the public and staff across England. But with the best will in the world, this can only ever involve a tiny proportion of stakeholders. There is still a massive job to engage with the public and convince staff that these changes are going to deliver benefits.

Making Darzi a reality will require leadership from all of those in the service. Of crucial importance will be clinical leadership in both acute and community sectors. Lord Darzi has promised that changes to local services will not happen without stakeholders’ agreement. As a safeguard, changes will require agreement between hospital consultants and GPs. This will require both groups to set aside self interest and design services that will meet patient requirements and be clinically safe services.

So while the central policy message may not be new, Darzi’s proposals do provide a much needed blueprint for change. However history suggests, we should expect a long campaign.