When I first heard about Ara Darzi's "once in a generation review" which is published today, I was doubtful that we needed it. It seemed like a positive rather than a negative way to kick the NHS into touch pending the election, which of course never happened. We've had no end of reviews of the NHS; we are still embarked on the 10-year plan created by Alan Milburn and have made small progress with "Our health, our care, our say" launched by Patricia Hewitt in 2006.
The problem with the NHS, says Alan Maynard, the hard-boiled economist, is that it scores eight out of 10 for bright ideas and four out of 10 for implementation. One of the main reasons it's poor on implementation is the constant stream of new ideas, and Darzi's report is to be followed in a week by what a department of health insider called a "deluge of strategies." There is no need to bother implementing idea A because another ideas B, C, and D will be a long in a minute and A will be completely forgotten (or will be recirculated as idea F in a year's time). Yet implementation not new ideas is the key to success for any organisation. If, for instance, we were to stop inventing new treatments but implement all we know now we'd save millions of lives.
The essence of Darzi's report (pdf) is that we are going to move from quantity – more money, more clinicians, more operations – to quality, which he defines as clinically effective, personal, and safe care. Ironically the public tends to think that it gets high quality care now, failing to recognise the dramatic variation in outcomes around the country and from ward to ward even within the same hospital. The public is rightly worried about hospital infection, but people don't tend to know that they have a one in 10 or higher chance of suffering an adverse event when admitted to hospital and a one in a 100 chance of being killed. Researchers have known this for more than 20 years, but we have been very slow to respond. So one of Darzi's problems is that he may be offering people something they think they already have.
But perhaps the most difficult part of quality to deliver is the personal bit. Patients may not know that they are getting clinically poor care, but they know whether or not it's personal – and mostly it isn't. And it's not surprising that it isn't, because the NHS was never designed to deliver personal care. One of the famous sayings of the quality improvement movement (which has been labouring away in healthcare for 30 years) is that "every system delivers exactly what it is designed to deliver". The NHS is designed to get people treated, to get them "done", and for those who remember when there was no access to healthcare that was wonderful. Now people want more, but it's not easy to transform an organisation of over a million people.
And Ara Darzi knows that. He writes: "Quality care cannot be mandated from the centre – it requires the unlocking of the talents of frontline staff." Yet his report inevitably is a mandate from the centre. He hopes that the 2000 clinicians and 60,000 he has spoken to in preparing his report will want to lead the change, and no doubt some of them will. The NHS has always had great entrepreneurs doing wonderful things, but often these innovations don't spread to the next ward, let alone to the whole NHS.
Hence an emphasis on incentives and leadership. GPs will be paid more to deliver the high quality care envisaged by Darzi, and hospitals as well will be rewarded for delivering not just lots of care but high quality care. Then there will be the incentive of information. The hope is that seeing yourself or your hospital at the bottom of the league table will spur you to action. It may well, however, spur you to dispute the validity of the data. We've been talking about giving patients information for years – ever since the scandal in Bristol over cardiovascular surgery and cardiac surgeons have made progress. It isn't, however, easy. Fail to adequately "risk adjust" for the complexity of cases and doctors are reluctant to treat them, or, as happened in the US, over-adjust and surgeons leap on the most complex.
Improved quality also depends crucially on leadership from clinicians, particularly doctors. You can't reform the health service if the doctors think your reforms are a pile of crap, which is roughly what they do think. Ara Darzi was chosen to conduct this review because he's a world famous surgeon and an all-round good bloke. Surely he could bring those dark-eyed dinosaurs in the BMA into line. Well, he's tried with a thousand conversations and dinners, but the BMA's reaction is lukewarm to put it mildly.
So Darzi's report is full of worthy if not very original ideas, but the challenge is not in writing the report but in making it happen. And the way things look now that may be more a task for the Conservatives than Labour.