NH
S N
ext
Sta
ge R
evie
w
NHS Next Stage Review
Professor the Lord Darzi KBEParliamentary Under-Secretary of State
NH
S N
ext
Sta
ge R
evie
w
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?
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
w
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…
NH
S N
ext
Sta
ge R
evie
wVariation in care across the country
7
Fewer GPs and worse care in areas with greatest need(Areas with the fewest GPs have poorer quality and outcome (QOF) scores)
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
wStaying healthy
Population-level interventions
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
wLong-term conditions
Create a web of care with the individual at the centre
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
w
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
NH
S N
ext
Sta
ge R
evie
w
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:
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
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
NH
S N
ext
Sta
ge R
evie
w
“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