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82435-COI-CMD Paper-COVER 3/10/07 18:20 Page 1

NHS NEXT STAGE REVIEW

Interim reportOctober 2007

82435-COI-CMD Paper-COVER 3/10/07 18:20 Page 2

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Policy Estates HR/Workforce Commissioning Management IM & T Planning/ Finance Clinical Social Care/Partnership Working

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ROCR ref: Gateway ref: 8857

Title NHS Next Stage Review Interim Report

Author Professor Lord Darzi

Publication date 04 Oct 2007

Target audience PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Foundation Trust CEs, Medical Directors, Directors of PH, Directors of Nursing, PCT PEC Chairs, NHS Trust Board Chairs, Special HA CEs, Directors of HR, Directors of Finance, Allied Health Professionals, GPs, Communications Leads, Emergency Care Leads, Local Authority CEs, Directors of Adult SSs, Directors of Children’s SSs, Voluntary and Independent Sector Organisations

Circulation list (See above)

Description Interim report by Lord Darzi on the NHS Next Stage Review

Cross reference N/A

Superseded documents N/A

Action required N/A

Timing N/A

Contact details NHS Next Stage Review Team Room 524A, Richmond House, 79 Whitehall, London SW1A 2NS 020 7210 3000 Email: ournhs@dh.gsi.gov.uk http://www.nhs.uk/ournhs

For recipient’s use

our nhs, our future

1Contents

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2

3

5

6

7

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Summary letter 3

Introduction 9

The journey so far 11

A world-class NHS – our vision 17

A fair NHS 19

A personalised NHS 23

An effective NHS 34

A safe NHS 42

A locally accountable NHS 46

How to get involved 54

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3

Dear Prime Minister, Chancellorof the Exchequer, and Secretaryof State for Health,

As you know, I’ma doctor not apolitician. That’swhy you asked meto take on this task –

and it’s why I agreed.With my colleagues,

I have spent my careercommitted to doing my best to

provide patients with high quality NHScare. And I am continuing to work asan NHS surgeon.

But the reason I accepted yourinvitation to lead this Review isbecause I believe that it is an importantopportunity to take stock of theprogress of recent years in improvingthe quality of care and up the pace ofimprovement going forward.

I want to make the most of thisopportunity to listen to the views ofpatients, staff and public on how todo this. I have already heard fromthousands of people in the weekssince the Review began – and theirviews have helped shape this interimreport. I want to continue to giveeveryone the chance to contributeduring the second stage of the Review.

My aim is to convince and inspireeveryone working in the NHS, and inpartner organisations, to embrace andlead change. I have met with somescepticism, including from clinical

colleagues. I was expecting it. I toldthem I would not have agreed to getinvolved if this was a means ofavoiding awkward decisions. I believehowever that this is a chance to shapethe future of the NHS in a new way.

My assessment is that the NHS isperhaps two thirds of the way throughits reform programme set out in 2000and 2002. In my visits across the NHSI have detected little enthusiasm fordoing something completely different;instead the majority opinion is that thecurrent set of reforms should be seenthrough to its conclusion. I agree.

Making the improvements that peopleexpect us to achieve will not be easy.Improving the quality of care meansaccepting that fundamental changewill have to happen. No-one shouldsee this Review as a way of slowingdown or diluting what we need to do.If anything we should be seeking torespond to the rising aspirations ofpatients and the public and be moreambitious, to help all members of ourdiverse population live longer, healthierlives, especially those least able to helpthemselves.

I believe passionately that, through thisReview, we all have an opportunity toshape the NHS for the 21st century. Ourambition should be nothing less thanthe creation of a world class NHS thatprevents ill health, saves lives andimproves the quality of people’s lives.

Summary letter

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Summary letter

Some aspects are already world class.The challenge is to ensure that everyaspect matches the best – to take ourhealth service from good to great.

This interim report is the start ofdeveloping this vision for the next tenyears. It has two purposes. It describesthe key elements of a vision – an NHSthat is fair, personal, effective and safe– and sets out the immediate actionsthat should now be taken to makeprogress towards it.

I have spent the last three monthsvisiting different NHS organisations andhearing the views of staff. I haveparticipated in lively debates withpatients and the public about howthey feel the NHS and its partnersshould respond to their needs.

This report is based on those views,visits and discussions. It acknowledgesthe progress that NHS and other staffhave already made towards achievingthat vision, challenges them to beambitious in striving towards it, andsets out the scope for improvementand the challenges we need to meetover the second stage of the Review.

I believe that this vision for the futureshould not be just mine – or theGovernment’s – but a vision for thefuture of health and healthcare inEngland that is developed and ownedby patients, staff and public together.

THE JOURNEY SO FARWe are not starting from scratch inachieving this vision.

Back in 1997, the NHS was in relativelypoor health. Investment levels hadvaried considerably over previousdecades, hampering proper planning.Although many patients enjoyed goodcare, many more experienced thetrauma of poor access to primary care,long waiting times, old buildings and awinter crisis that was as predictable asthe season itself.

Since then, the NHS has vastlyimproved. I only have to look at myown experience to see the progressthat has been made. There are morestaff in my team; our patients do notwait as long for operations; and theircare is of a higher quality and is morepersonalised.

Those experiences are echoed acrossthe country. The sustained investmentsince the NHS Plan (2000) has allowedthe NHS to grow. As a result, there aretens of thousands more doctors,nurses and other NHS staff, hundredsof new or refurbished facilities andthousands of new pieces ofequipment. Together with the reformsthat have been put in place this hashelped reduce waiting times, raisestandards and improve the quality ofcare the NHS provides – care that is stillprovided according to clinical need andnot ability to pay.

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But in spite of this improvement, theviews I have heard from patients, staffand the public do not always fit withthe description above.

Patients have told me that they stillsometimes feel like a number ratherthan a person. They do not know howto access the services they need tohelp them stay well and independent.They cannot always see a GP orpractice nurse when they need to.

In short, patients lack ‘clout’ inside ourhealth care system.

The public say they are sometimesconfused about which NHS servicethey should use. They hear a lot aboutchanges but do not know why theyare being made.

Some staff tell me that they haven’tbeen listened to and trusted. They donot feel that their values – includingwanting to improve the quality of care– have been fully recognised. Nor dothey feel that they have always beengiven the credit for the improvementsthat have been made.

The NHS could therefore continue tomake incremental improvements.

This would not resolve the frustrationsI have identified. It would meanaccepting that services stay broadly asthey are now. It would mean acceptingsteady progress rather than a step-change in reducing mortality rates.It would mean the NHS facing

mounting pressure from rising publicexpectations and from major publichealth challenges.

A WORLD CLASS NHSAlternatively we can choose to beambitious and set out a clear vision fora world class NHS focused relentlesslyon improving the quality of care.

Based on what I have heard and seen,I believe that only this approach allowsus fully to respond to the aspirations ofpatients, staff and the public. Only thisapproach enables us to deliver the kindof personalised care we all expect.

Our vision should be an NHS that is:

• Fair – equally available to all, takingfull account of personalcircumstances and diversity

• Personalised – tailored to the needsand wants of each individual,especially the most vulnerable andthose in greatest need, providingaccess to services at the time andplace of their choice

• Effective – focused on deliveringoutcomes for patients that areamong the best in the world

• Safe – as safe as it possibly can be,giving patients and the public theconfidence they need in the carethey receive.

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Summary letter

This is not about changing the wayNHS is funded or structured.Successive reports have shown notonly that our system is fair, but alsothat other comparable systems are, inkey respects, less efficient. We nowneed to:

• move beyond just expanding thecapacity of the NHS and focusrelentlessly on improving thequality of care patients receive

• be ambitious – respond to theaspirations of patients and thepublic for a more personalisedservice by challenging andempowering NHS staff and otherslocally

• change the way we lead change –effective change needs to beanimated by the needs andpreferences of patients,empowered to make theirdecisions count within the NHS;with the response to patient needsand choices being led by clinicians,taking account of the bestavailable evidence

• support local change from thecentre rather than instructing it –providing that the right reformedsystems and incentives are in place

• make best use of resources toprovide the most effective care,efficiently.

IMMEDIATE STEPS

Some immediate steps should be takenahead of my final report:

1.To help make care fairer theSecretary of State has announced acomprehensive strategy for reducinghealth inequalities, challenging theNHS, as a key player, to live up to itsfounding and enduring values.

2.To help make care more personal,patient choice should be embeddedwithin the full spectrum of NHSfunded care, going beyond electivesurgery into new areas such asprimary care and long termconditions:

• New resources should be investedto bring new GP practices –whether they are organised on thetraditional independent contractormodel or by new private providers– to local communities where theyare most needed, starting with the25% of PCTs with the poorestprovision

• Newly procured health centres ineasily accessible locations should beoffering all members of the localpopulation a range of convenientservices, even if they choose not tobe directly registered with GPs inthese centres

• PCTs should introduce newmeasures to develop greaterflexibility in GP opening hours,

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7

including the introduction of newproviders. Our aim is that, overtime, the majority of GP practiceswill offer patients much greaterchoice of when to see a GP,extending hours into the eveningsor weekend.

3.To support the delivery of moreeffective care, we should establish aHealth Innovation Council to be theguardians of innovation, fromdiscovery to adoption.

4.To help make care safer, we shouldsupport the National Patient SafetyAgency (NPSA) in establishing asingle point of access for frontlineworkers to report incidents: PatientSafety Direct. And to reduce rates ofhealthcare associated infections stillfurther we should:

• legislate to create a new health andadult social care regulator withtough powers, backed by fines, toinspect, investigate and intervenewhere hospitals are failing to meethygiene and infection controlstandards

• give matrons further powers toreport any concerns they have onhygiene direct to the new regulator

• introduce MRSA screening for allelective admissions next year, andfor all emergency admissions assoon as practicable within the nextthree years.

5.We should ensure that any majorchange in the pattern of local NHShospital services is clinically led andlocally accountable by publishingnew guidelines to make clear that:

• change should only be initiatedwhen there is a clear and strongclinical basis for doing so (as theyoften may well be)

• that consultation should proceedonly where there is effective andearly engagement with the publicand

• resources are made available toopen new facilities alongside oldones closing.

Any proposals to change services willalso be subject to independent clinicaland managerial assessment prior toconsultation through the Office ofGovernment Commerce’s Gatewayreview process.

THE SECOND STAGE OF THEREVIEWBuilding on these immediate actions,the second stage of the Review will setout how we can deliver the vision for aworld class health service through alocally accountable NHS in whichhealth and social care staff areempowered to lead change, supportedby the right reformed systems andincentives.

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Groups of health and social care staff –over 1,000 people in total – will beestablished in every region of thecountry to discuss how best to achievethis vision across eight areas of care:

• Maternity and newborn care• Children’s health• Planned care• Mental health• Staying healthy • Long-term conditions• Acute care• End-of-life care

I want each group to listen to patients,the public and others to identify whatit would take over the next decade tocommission and provide world classcare, using the best available evidence,and set out their plans to deliver onour vision of a fair, personal, effective,safe and locally accountable NHS.

I also have come to the view that theNHS could benefit from greaterdistance from the day to day thrust ofthe political process, and believe thereis merit in exploring the introduction ofan NHS Constitution. I have thereforeasked NHS Chief Executive, DavidNicholson, to chair a national workinggroup of experts to consider the scope,form and content that such aConstitution might take.

These steps – local and national – willform the basis for a vision for a worldclass NHS, to be published in June2008 in time for the 60th anniversaryof the NHS.

Best wishes

Professor the Lord Darzi ofDenham FREng, KBE, FMedSciParliamentary Under Secretary of State,Paul Hamlyn Chair of Surgery ImperialCollege London, Honorary ConsultantSurgeon, St Mary’s Hospital and theRoyal Marsden Hospitals NHSFoundation Trust

Summary letter

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The NHS has cared for us all fornearly 60 years. As an NHSsurgeon, working in partnership

with professionalcolleagues across theNHS, I am proud tohave learnt my skillsin the NHS and tohave given back to

the NHS as part of aprofessional team. I know

we cannot take the services thatthe NHS and its partners provide forgranted.

That is why I believe the NHS NextStage Review is so important. It is achance to take stock of progress madein recent years towards the vision of apatient-centred NHS set out in the NHSPlan (2000). It challenges us to lookahead for the next decade andconsider what more we could andshould be doing to respond to people’srising aspirations. Everyone deservesthe best possible health and healthcareand we should challenge people andcommunities to raise their aspirationsto achieve it.

The terms of reference for the Reviewset out a number of challenges:

• Working with NHS staff to ensurethat clinical decision-making is at theheart of the future of the NHS andthe pattern of service delivery

• Improving patient care, includinghigh-quality, joined-up services forthose with long-term or life-threatening conditions, and ensuringpatients are treated with dignity insafe, clean environments

• Delivering more accessible and moreconvenient, integrated care reflectingbest value for money and offeringservices in the most appropriatesettings for patients

• In time for the 60th anniversary ofthe founding of the NHS,establishing a vision for the nextdecade of the health service which isbased less on central direction andmore on patient control, choice andlocal accountability and whichensures services are responsive topatients and local communities,whatever the circumstances

To help me understand how best tomeet these challenges I have spent thelast three months visiting local healthcommunities and hearing the views ofstaff. I have participated in livelydebates with patients and the publicabout the priorities they feel the NHSand its partners need to adopt torespond to their needs. Specifically Ihave:

• visited and spoken to 1,500 NHSstaff in 17 NHS organisations acrossthe country

IntroductionIntroduction

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Introduction

• taken part in a nationwide day ofdetailed discussions on the prioritiesfor the NHS with 1,000 patients,public and health and social carestaff in nine different towns andcities

• met with representatives of 250stakeholder groups representing thefull diversity of our population andstaff

• read more than 1,400 letters andemails from people up and down thecountry

• in preparation for the second stageof the Review, brought together over1,000 doctors, nurses and otherhealth and social care staff in groupsin every part of the country to focuson discussing how best to plan andprovide care for patients

• reviewed the evidence available forwhat matters to patients, staff andthe public, drawing on research fromthe NHS Leadership team this year.

The views that I have heard and theNHS organisations that I have visitedare the basis for this report. It is thestart of developing the vision that Ibelieve we need to renew for the NHS– a world class NHS that prevents illhealth, saves lives, improves the qualityof people’s lives and treats people withdignity and respect. It acknowledgesthe progress that NHS and other staffhave already made in achieving thatvision, describes the scope forimprovement that remains, and setsout the immediate steps we shouldtake and the challenges we need tomeet over the second stage of theReview.

This vision for the future should not bejust mine – or the Government’s – buta vision for the future ofhealth and healthcare inEngland that isdeveloped and ownedby patients, staff andpublic together.

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We are not starting fromscratch in achieving this vision.The NHS has made clear

progress over thelast decade.

Back in 1997, theNHS was in relativelypoor health.

Investment levels hadvaried considerably over

previous decades, hamperingproper planning. Although many

patients enjoyed good care, manymore experienced the trauma of pooraccess to primary care, long waitingtimes, old buildings and a winter crisisthat was as predictable as the seasonitself. The NHS simply was not bigenough or capable enough to meetpatients’ expectations.

Since then the NHS has vastlyimproved. I only have to look at myown experience to see the progressthat has been made. Compared with10 years ago:

• we have more staff – I used to be theonly colorectal surgeon in myhospital. Now I am one of a team offour surgeons working withcolleagues in a network that reachesout into primary care

• we can detect disease earlier andtreat more patients more quicklyfrom the moment they see their GP.My patients sometimes used to waitover a year for treatment. Now theyare likely to have waited a fewweeks, and even less when they aresuspected of suffering from cancerand require urgent surgery

• we have made systematic changes toimprove the quality of care – I usedto have corridor conversations withcolleagues about cases. We nowdiscuss each cancer case in a weeklymeeting as a multidisciplinary teamof clinicians to agree the bestrecommendation for each patient’scare

• we are providing more personal carewith greater dignity for patients – weused to have one part-time stomanurse, now we have two full-timestoma nurses, two specialist nursesand a nurse consultant, working tohelp local people and practitionersimprove the quality of people’s care.We have a colorectal patient usergroup which meets every threemonths with staff in my team,helping to personalise people’s care

The journey so far

I only have to look at my own experience to see the progressthat has been made

The journey so far

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The journey so far

• the operations we carried out usedto be highly invasive – most of whatwe do now is keyhole surgerydeveloped with the help of NHSinvestment in technology andtraining.

This progress is replicated right acrossthe country.

The NHS Plan (2000) diagnosed theproblems and wrote the prescriptionthat provided sustained,unprecedented investment to increasecapacity. Since then this investment hasallowed the NHS to grow. As a result,there are tens of thousands moredoctors, nurses and other NHS staff,hundreds of new or refurbishedfacilities and thousands of new piecesof equipment.

The NHS now sees and treats morepatients than ever before. Last year, onaverage every day, we saw over50,000 people in accident andemergency (A&E), held nearly 900,000GP consultations and took over 16,000calls to NHS Direct.

The NHS continues to provide carebased on clinical need and not abilityto pay and remains one of the fairesthealth systems in the world.

Care is more personalised than it was.New primary care services, such aswalk-in centres and NHS Direct, enablepatients to access and receive caremore conveniently. People should waitno longer than four hours in A&E and,if they really need to, can usually see aGP within 48 hours. More people withserious mental health problems arenow supported in their own homes,without the interruption to daily lifethat hospital admissions would bring.

The genuinely impressive reductions inmaximum hospital waiting times,unthinkable even a few years ago, willbe complete by December 2008.Consequently, patients will be able toexpect treatment, including operations,within a maximum of 18 weeks ofreferral by their GP – and much soonerif the GP suspects cancer. The averagewaiting time should be closer to nineweeks.

Better care now results in betteroutcomes for patients. For example,we have now substantially reducedcardiovascular disease mortality ratesmeeting the target four years early,and cancer mortality has also fallensignificantly. These outcomes willcontinue to improve – saving manymore thousands of lives each year.

Better care now results in better outcomes for patients

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Care is more safety focused. We nowhave systems in place to report andlearn from safety incidents, and we areusing this to prevent errors occurring inthe first place. A much stronger focuson cleanliness and infection control isenabling the NHS to make real

progress against MRSA.

These improvements aredown to the hard work ofall staff involved, and areimprovements to be proud

of. A number of existingreforms support these

improvements and help make carefairer, more personal, more effective,and safer. Independent bodies like theNational Institute for Health andClinical Excellence (NICE), theHealthcare Commission (HCC) and theCommission for Social Care Inspection(CSCI) have been created to set

standards and hold organisations toaccount for meeting them.

Reforms such as payment by results(making it easier for money to followthe patient) and, in some places,effective practice-based commissioningare beginning to make it easier forpatients to choose where they aretreated – and to get care more locally.The commissioning process itself isstarting to drive improvements in thequality of care provided to patients –although there remains significantwork to do to improve commisioningto fully support the delivery of ourvision.

NHS hospitals, in many cases as NHSfoundation trusts, are now moreclearly accountable to localcommunities and are better placed to

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innovate to improve the quality of theservices they provide.

Independent sector providers have alsohelped extend choice, add capacityand spur innovation. They haveincreasingly become a fixture of NHSprovision, with three-quarters of amillion NHS patient care episodesperformed by the independent sector

to date.

This evidence of progress isconfirmed by externalevaluation. A study earlier

this year by theCommonwealth Fund, an

independent health research group,found that our improvements havemade this country the top healthcaresystem among five comparatorcountries, rating the UK better overall

than Australia, Canada, Germany, NewZealand and the United States – animprovement since the previous reportfrom the same group.1

So, if the NHS is objectively in suchgood health, why – subjectively – dothe views I have heard from patients,the public and staff not always fit withthe description above?

Patients have told me that they stillsometimes feel like a number ratherthan a person. The research showsthey want to be treated as people, notas sets of symptoms or conditions.They want care to fit into their lives,not have to fit their lives around thecare they receive. And of course theywant us to get the basics right – theyexpect competent staff, to be treatedwith dignity and respect, their notes to

1 Commonwealth Fund: Mirror, Mirror on the Wall: An international update on the comparative performance ofAmerican healthcare, May 15, 2007 (Updated May 16, 2007) Volume 59

The journey so far

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be available and for buildings to beclean. Research shows us that while80% of patients are satisfied with theirlast hospital inpatient visit, 56% ofhospital patients told us they did nothave an opportunity to talk to adoctor.

The public say they are sometimesconfused about which NHS servicethey should use. They want us to treatall patients fairly – based on need, notability to pay, or ability to ‘work’ thesystem – and they want the NHS to bethere for them when they need itmost. They hear a lot about thereforms that are being made, but donot know the reasons why thechanges are being made and how itwill deliver higher quality than before.We need to respond to these concernsby being much clearer about the casefor change where it is necessary, andshowing how it will improve quality.

Staff often feel left out of the changesthat are happening. It is true that insome cases that is because greaterpower for patients is challenging oldways of doing things, but in othercases staff can see that changes needto be made. They now need the spaceto act on this.

In part, that means changing theconceptualisation but not the necessity

of reform. I recognise this from myown experiences. I don’t discuss themerits of payment by results with mycolleagues in the scrub room or thenurses’ station. There is a time and aplace for that – but what we talk andcare about are the cases we havedone, the techniques we are using andthe outcomes we are getting for ourpatients.

I’ve seen that targets can be effective –and I have seen the difference theymake for patients in terms of drivingprogress on reducing waiting times –but they are not always the answerand sometimes they can seemperverse.

I have considered all of these points asI have put together this interim report.We should acknowledge theundoubted progress made over the lastdecade – the NHS is not only back onits feet, it is world class in some areas.It could continue to move forward onthis basis. That would meanincremental improvements in care butit would not resolve the frustrationsand shortcomings I have identified. Thechallenge is to move from world classin some aspects to world class in all –to take the NHS from ‘good’ to ‘great’.

I do not believe we should change theway the NHS is funded or structured.

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Successive reports, including the NHSPlan and the reports from DerekWanless2, have shown not only thatour system is fair, but also that othercomparable systems are, in someimportant respects, less efficient. Thelast few years have demonstrated that,through investment in primary,community, hospital and social care,the current model can deliversignificant improvements and gives usa meaningful chance of meeting thechallenges of the future.

But I do believe that we can onlyachieve our vision – and genuinely liveup to the founding principles of theNHS – by doing things differently.This means:

• moving beyond expanding thecapacity of the NHS and renewingour focus on improving the quality ofcare patients receive

• being ambitious – responding to theexpectations of patients and thepublic of a more personalised serviceby challenging and empowering NHSstaff and others locally to deliver onthem

• changing the way we lead change –effective change needs to beanimated by the needs andpreferences of patients, empoweredto make their decisions count withinthe NHS; with the response to thosepatient needs and choices led byclinicians, taking account of the bestavailable evidence.

• supporting local change from thecentre rather than instructing it –ensuring that the right reformedsystems and incentives are in place

• making best use of NHS resources toprovide the most effective care,efficiently.

The journey so far

2 Securing Our Future Health: Taking a long term view, 2002 and securing good health for the whole population:Final Report, February 2004

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Over the last three months,I have spoken to patients, thepublic and NHS staff about

what makes aworld-class NHS.I know that thereis real enthusiasmto be ambitiousand renew our

vision for an NHS fitfor the 21st century.

I am convinced we should lift oursights. Our aim should be nothingshort of creating a world-class NHSthat strives relentlessly to improve thequality and personalised nature of theservices and care patients receive.

Achieving this means responding tothe things that matter most to people.I have heard repeatedly that careshould be:

• fair

• personalised

• effective

• safe

As a doctor working in the NHS,I agree. We should judge success bythese criteria. I believe our visionshould be of an NHS that provides carethat is:

• equally available to all, taking fullaccount of personal circumstancesand diversity

• personalised to the needs and wantsof each individual, especially themost vulnerable and those in greatestneed, providing access to services atthe time and place of their choice

• focused on delivering qualityoutcomes for patients that areamong the best in the world

• as safe as it possibly can be, givingpatients and the public theconfidence they need in the carethey receive

The next four chapters set out a visionfor the future in each case: why thesefour aspects of quality matter; whatwe need to change; and the steps –immediate and over the second stageof this Review – I believe we must nowtake. I then set out how we can deliveron them – through a locallyaccountable NHS in which health andsocial care staff are empowered to leadchange, supported by the right systemsand processes.

During the second stage of the Review,groups of NHS and social care staff willbe established in every region of thecountry to discuss how best to achievethis vision for each of eight areas ofcare:

• Maternity and newborn care

• Staying healthy

• Children’s health

A world-class NHS – our vision

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• Planned care

• Acute care

• Mental health

• Long-term conditions

• End-of-life care

I want each group to listen to patients,staff and the public and identify whatit would take over the next decade toprovide world-class care, using the bestavailable evidence and help to reducehealth inequalities. They will considerthe priorities identified by patients,public, staff and partners and set outtheir plans to deliver on our vision.

A world-class NHS – our vision

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VISION A fair NHS must continue to beequally available to all, taking

full account ofpersonalcircumstancesand diversity.

A FAIR NHSMATTERS

Our evidence shows thatthe public and staff care deeplyabout the NHS and that one of

the things that matters to them is thatpatients are treated fairly – based onneed, not ability to pay.

One of the great triumphs of the NHS,largely tax-funded, universal and freeat the point of need, is that it is fairand equitable. The public are rightlyproud of this and throughout the lastfew months I have been struck by theirfundamental support for this principle.When we asked participants at theconsultative event whether theyagreed that the NHS should continuelike this into the 21st century, anoverwhelming 92% of people said yes.

The majority of the public believe thatthey have a responsibility to fund theNHS, that the NHS has enough money,but that it is not always well used.

WHERE WE ARE NOWAlthough major improvements in carehave been made over the last decade –as I described in chapter 2 – theseimprovements have not been universal.The breadth and scale of inequalitieswithin England are still striking. Majorinequalities exist in life expectancy,infant mortality and cancer mortality.Too many of the poorest communitiesexperience the worst health outcomes.Although the nation’s health hasimproved over the years, including thehealth of those born with fewersocioeconomic advantages, a boy bornin the City of Manchester today is nowlikely to die almost ten years earlierthan a boy born in the Royal Boroughof Kensington and Chelsea.

The gap in life expectancy between themost deprived and least deprived areashas widened, despite improvements inlife expectancy in the most deprivedareas. Someone’s social status orwhere they live should not affect whenthey die.

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A fair NHS

There is also evidence that theopportunity to access healthcare isactually worse in areas of greater need.The maps below show how areaswhere life expectancy is lowest formen (red, map 1) – concentrated inLondon, the Midlands, Yorkshire, NorthWest and North East – broadly matchthe areas with fewer GPs per head(red, map 2). The picture is the samefor women.

Mid Devon PCT, for example, has overtwice as many GPs per head ofweighted population as Oldham PCT.

And sadly it turns out that our currentGP system has actually led to a larger

inequality in the distribution of GPsacross the country over the past twodecades even as the overall number ofGPs has increased. We therefore needto open up the supplying of GPservices in deprived communities to awider range of providers – be they GPpractices or new private GP providers –so as to seek to improve equity in theavailability of GP services.

I also believe we should ensure thattaxpayers’ money is used well. Whencompared with other countries, theNHS should achieve high levels ofproductivity because of the way wefund care and our primarycare system in particular.

Map 1Male life expectancy at birth by localauthority area, 2002–04

Upper quartile (78.4 to 80.8)(77.5 to 78.4)(76.6 to 77.5)(75.5 to 76.6)Lower quartile (72.3 to 75.5)

Map 2GPs per 100,000 weightedpopulation, by PCT

Upper quartile (71 to 95)(65 to 71)(59 to 65)(53 to 59)Lower quartile (42 to 53)

Source: Office for National Statistics, Life Expectancy2002–2004

Source: Information Centre – Workforce Census 2006

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30

25

20

15

10

5

0

Num

ber

of t

rust

s

150–200

200–250

250–300

300–350

350–400

400–450

450–500

500–550

550–600

600–650

650–700

700–750

750–800

800–850

850–900

900–950

950–1000

Specialist & Teaching Hospitals

FCEs per consultant

All other Hospitals

Finished consultant episodes per whole time equivalent consultant, 2004/05

However, there are still areas in whichsignificant variations in productivityexist – and in which we could do moreto improve the way we measureproductivity. For example, the graphbelow shows how numbers of‘finished consultant episodes’ perconsultant vary across NHS trusts on atypical index of productivity.

SCOPE TO IMPROVETo create a fairer NHS, we have tofocus on improving access to healthand social care services for people indisadvantaged and hard-to-reachgroups and those living in deprivedareas. This also means making servicesmore personal: designing anddelivering services that fit with people’slives will help to reduce inequalities inhealth and social care outcomes.

I know from what I have seen aroundthe country that, while the NHS has abig part to play, the NHS cannot dothis on its own. Nationally, cross-government action needs to focus onthe wider social determinants ofhealth, such as early childdevelopment, poverty, lifestyle, housingetc. And locally the most successfulaction happens when differentagencies work together. PCTs have akey role in working with localauthorities, Local StrategicPartnerships, communities, industry,the voluntary and private sector andindividuals to ensure a broaderapproach and focused action.

Source: Hospital Episode Statistics 2005/06 and Information Centre: Workforce Census Sept. 2005

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NEXT STEPSLocally, the eight clinical pathwaygroups in each region, described inchapter 3, will consider as part of theirwork how to improve fairness in eachpathway.

Nationally, the Secretary of State hasrecently announced a comprehensivestrategy for reducing healthinequalities, challenging the NHS, as akey player, to live up to its foundingand enduring values of universality andfairness. This will aim to ensure thatthe NHS and other services:

• close unjustified gaps in health statusbetween individuals, whatever theirbackground

• ensure fair access to NHS services foreveryone

• treat all patients fairly, with highquality and good outcomes of carefor all.

A fair NHS

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VISIONA personalised NHS must betailored to the needs and

wants of eachindividual,especially themost vulnerableand those ingreatest need,

providing access toservices at the time

and place of their choice.

WHY IT MATTERSPeople have told me consistently thatpersonalised care matters. But we allknow – as professionals, friends,family, carers and users of the NHSourselves – that patients sometimesfeel treated as numbers, are made towait too long, do not have theircondition or treatment explainedsufficiently, feel lost in the system,receive poor ‘customer service’, aredenied choice, and experience basiclapses in care. Care may be personal,but too often it is experienced asimpersonal. And with patients cominginto contact with dozens of differentstaff along a typical care ‘pathway’ itmay only take one person toundermine a good patient experience.

Based on what I have heard, I have sofar identified four broad factors onwhich we could improve:

• access

• dignity and the patient as a person

• integrating care/partnership

• choice and personal control

IMPROVING ACCESS TO PRIMARYAND COMMUNITY CAREAs I set out in chapter 2, NHS staffhave helped deliver majorimprovements in access to care overthe last decade.

There have genuinely beentremendous improvements in access tocare in the past decade, particularly forplanned specialist care. When the ‘18weeks’ target is finally met in 2008,all patients referred by their GP formedical or surgical consultant-led carewill be entitled to choose to receiveclinically appropriate treatment quickeror as quickly as patients in anycomparable country. This was scarcelyimaginable 10 years ago. Already,patients should not need to spendmore than 4 hours in A&E (unless

A personalised NHS

NHS staff have helped deliver major improvementsin access to care over the last decade

A personalised N

HS

5

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there is a clinical need) and the greatmajority of patients can see their GPwithin 48 hours. What I have learnedfrom talking to people up and downthe country is that what matters is thatpatients really feel the difference – andthat we avoid reducing it to a form-filling exercise for staff. A key measureof success ought to be listening towhat our patients tell us about theirexperience.

The issue that has been raised with memost frequently during the first part ofthis Review is how difficult somepeople still find it to access primarycare.

More than 80% of NHS patientcontact takes place in primary care.Most secondary and tertiary care isaccessed through primary care, andmillions of people receive community-based care, for example for long termconditions. In my visits around thecountry, I have witnessed for myselfthe strength of our primary care andcommunity services. Our registered GPlist system is renowned internationally.Our primary care system co-ordinatescare for patients in a way few othercountries match. There are strong

bonds of trust between staff and theirpatients, families and carers.

But primary care faces a numberof pressing challenges in terms ofpeople’s experience of access.A number of steps have already beentaken. I believe we need to takefurther action now to meet thesechallenges.

It’s when my GP refers meonwards to a specialistclinic that the problemsstart – the left handdoesn’t know what theright hand is doing.

[Consultative event – Maidstone]

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EQUITABLE ACCESS TOPRIMARY MEDICAL CAREAs I described in chapter 4, there

is a correlationbetween areas withlowest lifeexpectancy andfewer GPs per headof population.

This is clearlyunacceptable and so theGovernment should invest

new resources to bring at least 100new GP practices, including up to900 GPs, nurses and healthcareassistants into the 25% of PCTswith the poorest provision, iefewest primary care clinicians, lowestpatient satisfaction with access andpoorest health outcomes. These newpractices will increase capacity andoffer an innovative range of services,including extended opening hours.They will improve health outcomes inthese areas, with more targeted andpreventive interventions that identifyand tackle illness at an earlier stage.

The vast majority of patients who seeGPs and other professionals in primarycare are highly satisfied with the carethey receive,3 but the consultativeevent in September showed that many

people are seeking the opportunity toaccess routine primary care from a GPin the evenings or at weekends. And aquarter of patients still report that theycannot book advance appointments attheir GP practice. It is also significantthat young working males and blackand ethnic minority communities aremore likely to report difficulties inaccessing GP services.

The following further action shouldtherefore now be taken:

• We should invest new resourcesto enable PCTs to develop 150GP-led health centres, situated ineasily accessible locations andoffering a range of services to allmembers of the local population(whether or not they choose tobe registered with these centres),including pre-bookableappointments, walk-in servicesand other services. The guidingprinciple will be to ensure that anymember of the public can access GPservices at any time between 8amand 8pm, seven days a week. Thesecentres will reflect local need andcircumstance and maximise the scopefor co-location with other community-based services such as diagnostic,therapeutic (eg physiotherapy),

3 2006/07 GP Patient Survey:http://www.dh.gov.uk/en/Publicationsandstatistics/PublishedSurvey/GPpatientsurvey2007/index.htm

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pharmacy and social care services.PCTs will be expected to commissionthese new health centres on a levelplaying field from existing GP groupsor other providers.

• PCTs will work with all new andexisting GP practices in their areas todevelop greater flexibility in openinghours – our aim is that at least halfof all GP practices will open eachweekend or on one or moreevenings each week. Where existingGPs do not start to offer theseextended services, PCTs will be ableto use the funding we make availablefor this to commission new servicesfrom other GPs, GP federations orother providers.

• We will ensure that an increasingproportion of the NHS paymentsmade to GP practices are linkedto their success in attractingpatients, and the views of theirpatients, including the ability tobook advance appointments andthe ability to see a GP within 48hours.

• Later this month key informationabout all GP practices – includingthe results of the patient survey,practice opening times andperformance against key quality

indicators – will be madeavailable on a single website,NHS Choices, via www.nhs.uk.This service will provide people withreliable and accessible information onGP practices to help them choosewhich one is likely to best meet theirneeds, and – if they are not satisfied– how to change their practice.

I will also be considering whether moreconvenient hours should apply toservices provided in secondary caresettings. Providers should certainly beconsidering whether to make bookableslots available in the evenings and atweekends for patients requiringoutpatient appointments.

OUT-OF-HOURS SERVICESDuring the first part of this Review,I have heard many people say that theyfind it confusing to know which NHSservice to access for routine or urgentcare when their GP practice is notopen. This matters especially forpeople with long term conditions whoare usually cared for by staff at thelocal GP practice, but whose conditiondeteriorates at a time when thepractice is shut. Should they go toA&E? Ring NHS Direct? Find a walk-incentre? Phone the local out-of-hoursnumber if they can find it? Try thepharmacist? Wait until the morning?

Our aim is that at least half of all GP practices will openeach weekend or on one or more evenings each week

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I believe that commissioners andproviders need to understand howpeople are accessing services and usethis information to ensure they areplanning and providing the right mixof services to meet people’s needs.

We need to find a way of enablingpeople with different lifestyles toaccess care in ways that suit them,while ensuring that everyone knowshow best to access care, particularlyurgent care, when they need it. Andwe need to find ways to engagepeople so that minor symptoms orlifestyle risks are not ignored until theyhave become established diseases. Inparticular, we need to do this for thosepeople less equipped to engage withtraditional general practice, whofrequently lead, busy lives and find ithardest to find time to see their GP.

As I said in my London Review4, weshould consider options to improveand simplify access for the public tourgent healthcare by exploring theintroduction of a single three-digitnumber in addition to the emergencyservices number 999. We will alsoidentify how pharmacies can bestsupport seamless urgent care forpatients. We know that peoplecontinue to have concerns about

prompt and easy access to medicines,including access to urgent repeatmedicines.

FUTURE STRATEGY ON PRIMARYAND COMMUNITY CAREI believe we need to go further still tomeet the challenges of the nextdecade. In part two of the Review, wewill develop a vision for primary andcommunity care services and a strategythat brings together these access issueswith the other main factorsdetermining personalisation,effectiveness, fairness and safety.

To help me, I will be drawing togetheran advisory board that includes GPs,community nurses and other healthand care professionals.

4 NHS London: Healthcare for London: A Framework for Action, 2007

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Advisory Board

Dr Sam Everington (GP from EastLondon and Member of BMA Council)

Dr Michael Dixon (GP from Devon andChair of NHS Alliance)

Prof Mayur Lakhani (GP fromLeicestershire and Chair of Council ofRoyal College of GPs)

Sir John Oldham (GP from Glossopand former-Head of ImprovementFoundation)

Ursula Gallagher (Community Nurseand Director of Quality, Ealing PCT)

Andrew Burnell (Community Nurseand Director of Provider Services andNursing, Hull PCT)

Paul Farmer (Chief Executive of MIND)

Anne Williams (President of ADASS)

Alwen Williams (CE, Tower HamletsPCT)

Dr David Colin-Thomé (NationalClinical Director for Primary Care)

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The review will need to include:

• the development of a vision ofworld-class primary and communityservices, capable of tackling existingchallenges of access and inequalityand promoting choice and control,as well as focusing ever morestrongly on promoting health,preventing illness and managing longterm conditions, not least in responseto the ageing of the population andlifestyle risk factors such as obesity.This is likely to mean reaching out tothe harder-to-reach groups amongour diverse population rather thanwaiting for them to present at theGP surgery

• a genuine understanding of what thebarriers and enablers are to achievingthis vision, in every local area

• proposals for new models of care –and linked proposals for changes toestates, workforce, training andaccountability

The review will also need to identifyhow the contractual andcommissioning arrangements forprimary medical care can continue toevolve to reflect these trends andchallenges, including:

• how to reshape incentives to providea stronger focus on health outcomesand continuous qualityimprovements; whether there shouldbe an independent process for settingand reviewing outcome measures in

the framework; and whether thereshould be greater flexibility for PCTs insetting outcomes that reflect localneeds and priorities

• how to provide a more equitable linkbetween the funding that a GPpractice receives and the number ofpatients for whom it provides care,and the relative needs of its localpopulation, based on the principlesthat practices should be fairlyrewarded for taking on new patientsand that ‘money follows the patient’if he or she chooses to switchpractices

• how to expand patient choice inprimary care, including exploring newmodels that enable patients to switchGPs more easily and register with GPpractices near their workplace, andhow to make it easier for the newentrants to start providing primarycare on contract to the NHS as ofright in underdoctored areas withouta slow and bureaucracticprocurement process

• how to involve the fullest possiblerange of service providers, includingexisting GP practices, voluntary sectororganisations and independent sectorproviders in developing innovativesolutions to tackling inequalities,improving patient access, developingmore responsive servicesand increasing patientchoice.

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The introduction of nationally procuredindependent sector providers inplanned care has been successful inintroducing innovation and changingthe culture of surgery. As we movefrom expanding capacity to focus oncreating a more personalised service,so the focus of the independent sectorshould shift to helping services locallyto respond quickly to patients’ needs.This means a shift from nationalprocurement to locally procuredservices and a greater role for theprivate and voluntary sectors in primaryand out-of-hospital care. I believe thatthe innovative practice thatindependent sector providers can bringwill help realise dramatic improvementsfor patients and challenge theestablished ways of working amongNHS organisations.

DIGNITY AND A FOCUS ON THEPATIENT AS A PERSONI know from my own patients howmuch they value being treated withdignity and respect. I hear it most fromolder people, when treated in hospital,that they who are concerned about:

• feeling neglected or ignored whilereceiving care

• being treated more as an object thana person

• feeling their privacy was notrespected during intimate care

• needing to eat with fingers ratherthan being helped with a knife andfork

• generally being rushed and notlistened to

I believe that the innovative practice that independent sectorproviders can bring will help realise dramatic improvements forpatients and challenge the established ways of workingamong NHS organisations

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• beds not being cleaned

• not being helped to wash

• mixed-sex wards.

At the nationwide consultative event inSeptember, more than 50% ofpatients, public and staff said thereneeds to be a lot or a fair amount ofimprovement in the dignity and respectwith which patients are treated.Information and communication werealso cited as important and requiringimprovement. And when things do gowrong, we also need to improve theway complaints are treated.

This is a key challenge for all clinicians.Nurses have a key role to play here,but we should all be constantlychallenging ourselves to find ways ofimproving the patient experience. For

example, when I am conducting alengthy operation and I know that theparent, spouse or carer of the patientwill be anxiously waiting for news, Iwill often arrange for them to receive acall to keep them informed. Similarly,we should ask ourselves, does thispatient really need to travel in to gettest results or to hear how successfulmy surgical intervention has been? Forexample, patients who are terminallyill, or dying, may find the bustle,limited privacy and noise of a busyward a stressful and inappropriateenvironment, or that they are subjectto clinical tests and interventions whichmay be of limited real value.

INTEGRATING CAREThere is evidence that one-stop care –for example by carrying out a numberof diagnostic tests together, byco-locating care under one roof, or by

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making better use of information andinformation technology – helpsimprove the effectiveness and safety ofcare.5 Basing that care where it is mostneeded also increases its connection tolocal communities, eg locatingchildren’s health services on extendedschool sites.

Integrating care is also a key driver ofpersonalisation because, for example,there are likely to be fewerappointments on a typical pathway,greater familiarity between patient andstaff, better information for thepatient, and a more ‘seamless’experience for the patient. Designingservices in terms of care pathways isthe best way to ensure that the qualityof care and the patient’s perspectiveare foremost, with organisationalboundaries a secondary consideration.This pathway approach will be takenlocally for part two of the Review.At the heart of this will be therelationship between local governmentand the local NHS. In effect, we need asingle health and wellbeing service inevery local community, shaped aroundthe user, not the organisation.

In my experience, the best care isprovided when there is collectiveaccountability for the outcomes ateach point along the pathway. Basedon this and on what I have heard fromNHS staff on my visits, we could do

more to ensure that current processes,including the NHS tariff, support thisapproach.

Not all of the conclusions of my reviewof London’s health services will applynationally, but one which I believe doesis the principle of ‘localise wherepossible, centralise where necessary’.As we know from the consultation forthe Our Health, Our Care, Our SayWhite Paper (2006), patients, familiesand carers prefer where possible to betreated close to home, and medicaladvances make this increasinglypossible. For instance, modern surgeryallows more day cases, outside majorhospital settings. The US health systemhas its challenges but the shift inoutpatient appointments from hospitalto community settings (90% inhospital in 1981; 50% in 2003)6

shows the scope for care to becomemore personalised in this respect.In England, it is estimated that over90% of outpatient appointments stilltake place in hospital.

CHOICE AND PERSONAL CONTROLPatients increasingly aspire to greatercontrol and choice over the servicesthey receive. I have seen how greatercontrol can be offered to patients byensuring that they have excellentinformation about the care optionsavailable to them and then by sharingdecisions between patient and

5 Making the shift: Key Sucesss Factors, July 2006, University of Birmingham Health Services Management Centre.6 Amercian Hospital Statistics; CSF; AHA Trendwatch Chatbook; CMS; Office of the Actuary

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clinician, leading to a personalised careplan tailored to the patient and agreedwith them and their carers.

So far, the drive towards greater choicein the NHS has been focused largelyon those patients referred for one-offelective treatments. Surely equallyimportant is offering more choice tothose patients who have to live formany years with an enduring medicalcondition. National patient groups arekeen that the NHS should increasinglyoffer such patients greater choice andcontrol, through the care planningprocess and supported with betterinformation and help.

I have also been impressed by what Ihave heard about the introduction ofindividual budgets in social care linkedto direct payments and individualbudget pilots, which have clearlytransformed the care of some socialcare users. From this, we need to learnhow to support and allow eligibleservice users increasingly to designtheir own tailored care and supportpackages. This could include personalbudgets that include NHS resources.As a first step, we will encouragepractice-based commissioners to useNHS funds much more flexibly tosecure alternatives to traditional NHS

provision where this would provide abetter response to an individual’sneeds, eg through respite care orsupport, installing grab rails to helpmaintain independence, self-monitoring equipment for people withlong term conditions, supporting carersof terminally ill patients, and so on.

NEXT STEPSThis chapter has set out my view ofthe difference personalised care canmake – and some of the steps weshould take now to act on this. In thenext stage of the Review, the eightclinical pathway groups in each SHAregion, described in chapter 3, willconsider how to improvepersonalisation in each pathway.They will do this in partnership withpatients, carers and their advocates.

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VISION An effective NHS musttherefore focus on delivering

outcomes forpatients that areamong the best inthe world.

Providing effectivetreatment and care is

what saves lives, improvesthe quality of people’s lives andprevents them getting ill. In my

experience it is also the reason thatmost staff join the NHS in the firstplace.

At the consultative events, we askedpeople what the top priority forimprovement was. ‘Getting the righttreatment and drugs’ came out top.

Preventive care matters because if theNHS can support people to makehealthier choices, they can avoid illhealth. The alternative is that smokingand unhealthy eating, for example,can lead to long term conditions suchas heart disease, diabetes, asthma andrespiratory problems such as chronicobstructive pulmonary disease.

There are currently over 15 millionpeople in England with a long termcondition and who are proportionatelyfar higher users of health services. Theyaccount for 55% of GP appointments,68% of outpatient and A&Eattendances and 77% of inpatient beddays.7

It also matters because it can providebetter value for money. This was anargument Derek Wanless made in his2004 report Securing Good Health forthe Whole Population. He made thecase for engaging the public in makinghealthier choices to save a potential£30 billion by 2022/23.

Effective care matters of coursebecause patients should get the bestoutcomes. The evidence also showsthat the most effective treatment isvery often the most efficient treatment.

An effective NHS

7 2005 General Household Survey

An effective N

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6

The Memorial Sloan-Kettering CancerCenter in New York provides anexcellent illustration of this point. Here,it is possible to see how volume andspecialisation can be linked to clinicalexcellence.

WHERE WE ARE NOW There have been clear improvements inlife expectancy over recent years. Malelife expectancy at birth in England is atits highest recorded level: 76.9 years in2003/05 compared with 74.8 years in1996/98. The same is true for women,with average life expectancy at birthstanding at 81.2 years in 2003/05compared with 79.8 in 1996/98.

These improvements in life expectancycan, in large part, be attributed totackling the major diseases – cancerand cardiovascular disease in particular.

Reductions in the last decade inmortality from these two diseases havesaved 50,000 and 150,000 livesrespectively through a combination ofbetter prevention, earlier detection andbetter treatment.

SCOPE TO IMPROVE Despite these improvements, thereremains much more we can do – interms of both effective prevention andeffective treatment. The scope forimprovement and the challengesfacing us can be illustrated by lookingat how we compare with othercountries, the variations in theeffectiveness of care that exist withinEngland, and how we are respondingto the emergence of new treatmentsand technologies.

Memorial Sloan-Kettering Cancer Center

Leng

th o

f st

ay (d

ays)

Other12

11

10

9

8

7

6

52.5 4.5 6.5 8.5

Mortality (%)

The size of the circle indicates the number of patients treated

Source: BMJ 2005: 330; 530-533 “What can the UK and US health systems learn from each other: Lois Quam and Richard Smith

10.5 12.5

Risk-adjusted mortality from cancer against length of stay for institutions inNew York State

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Although we have seen significantincreases in life expectancy over thelast decade, average life expectancy inEngland is still not as high as in someother countries. This is particularly trueof life expectancy for women.

Healthy life expectancy is notincreasing at the same rate as overalllife expectancy. For men in England in2003, the difference between overalllife expectancy at birth and theexpected number of years lived ingood health was 8.7 years. For womenthe difference was 10.7 years.

LatviaHungaryLithuania

EU-12 new averageEstonia

SlovakiaCzech Republic

PolandDenmark*Belgium*SloveniaEngland

MaltaIrelandGreece

EU averagePortugal

NetherlandsGermany

AustriaCyprusFinland

EU-15 averageSweden

LuxembourgItaly*Spain

France

*Denmark, Italy 2001; Belgium – 1997

England, EU countries andselected averages,latest data (2004*)

Source: England – Government Actuary’s Department. Web link www.gad.gov.uk/, All other countries – WHO, Health For All Database, June 2007. Web link www.euro.who.int/hfadb

Years

EU weighted averages

EU-12

EU-15

England

76.3

77.2

77.8

78.0

78.2

79.2

79.3

80.9

81.3

82.2

79.5

80.8

81.2

81.4

81.5

81.6

81.7

82.0

82.2

82.5

82.7

82.7

83.9

84.0

78.0

81.5

82.5

83.1

Female life expectancy at birth

Although we have seen significant increases in life expectancyover the last decade, average life expectancy in England is stillnot as high as in some other countries

74% of the public atthe Septemberconsultative eventagreed that the NHSshould focus more onpreventing peoplebecoming ill than onfurther reducingwaiting times.

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The September consultative eventillustrated the growing appetiteamong the public for the NHS to

provide greatersupport and adviceto help them stayhealthy. And withunhealthybehaviours currently

forecast to rise, theeconomic viability of the

NHS demands this.

We therefore need to pursue evidence-based interventions that supportpeople to make healthy choices andprevent ill health. For example, weneed to do more to tackle the problemof obesity, especially in childhood.

And as the NHS moves from being asickness service to a wellbeing service,we need services that engagemembers of the public much sooner,which help them understand their riskfactors and which equip them to takebetter control of their health and thelifestyle factors that affect it, such asexercise, obesity, smoking. In the nextstage of the Review, I will continue tolook at the case for shaping serviceswhich provide this kind of life andhealth checkup and at other routesthat encourage individuals to takegreater responsibility and control overtheir own health.

The focus on prevention and on earlyintervention means the Government

must ensure that the NHS is rapidlyable to adopt new vaccines or newapproaches to screening which arerecommended by the Joint Committeeon Vaccination and Immunisation andthe UK National Screening Committee.

And while the mortality rate for cancerhas fallen, there is still scope toimprove outcomes. For peoplediagnosed with cancer in 2000/01,before the NHS Cancer Plan tookeffect, the proportion who were alivefive years later is significantly lower inEngland compared with the best

8 Recent cancer survival in Europe: a 2000–02 period analysis of Eurocare – 4 data, Verdecchia et al (published 21 August 2007)

Breast cancer (women)

86.3%79.0% 77.8%

Sweden EU England

Cancer survival – percentage alive five years after diagnosis8

Colorectal cancer

59.8% 56.2%51.8%

Sweden EU England

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performing countries. This is largelybecause people in England werediagnosed with more advanced stagedisease. To improve survival rates weneed to focus on getting people tocome forward earlier when they havesymptoms and on ensuring they arediagnosed quickly.

Even within England there aresignificant variations in the quality andeffectiveness of care that peoplereceive.

Taking stroke as an example, the graphbelow shows that in the North East ofEngland patients were more likely tobe treated in stroke units with the sixkey features associated with highquality stroke care, namely:

• continuous physiological monitoring(ECG, oximetry, blood pressure)

• access to scanning within three hoursof admission

• access to brain imaging within24 hours

• policy for direct admission from A&E

• specialist ward rounds at least fivetimes a week

• acute stroke protocols/guidelines.

The statistics in the graph are far fromimpressive. And recently, manycountries, including Australia, Canadaand Germany, have taken advantageof new developments in stroke careand now give some patients a type ofclot-busting treatment that has beenshown to improve outcomes. Here, thistreatment is available in only a handfulof specialist centres.

We are also beginning to lag behindother countries in treating heart attackpatients with primary angioplasty (atechnique for unblocking arteriescarrying blood to the heart muscle asthe main or first treatment for patients

0 20 40 60 80 100

West Midlands

East Midlands

North West

South East Coast

London

North East

South Central

Eastern

South West

Yorkshire and Humber

Proportion of sites with acute strokeunits with five or six key features9

7.6

4.9

10.3

7.6

15.9

11.4

1-year mortality

30-day mortality

Primary angioplastyPre-hospital thrombolysisIn-hospital thrombolysis

0% 20%15%10%5%

Outcomes from angioplasty vsthrombolysis10

9 National Sentinel Stroke Audit 200610 Long-term outcome of primary percutaneous coronary interventions in prehospital and in-hospital thrombolysis for

patients with ST-Elevation Myocardial Infarction. Journal of the American Medical Association. 2006 296:174a-1756

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suffering a heart attack). For somepatients, the effectiveness of thisnew treatment compared with the

more conventionaltreatment ofadministeringthrombolysis is stark.I am pleased that theDepartment of

Health is running afeasibility study, looking

at the extent to which primaryangioplasty can be rolled out as

the main treatment for heart attack inEngland. But we need to accelerate thisto get it in place much faster.

We need to build an NHS that is ableto harness the tremendous benefitsthat can flow from new treatmentsand technologies such as these asswiftly as possible.

But effectiveness is not just aboutmaking use of the very latesttreatments and technologies. It is also

about ensuring that patients receivewell co-ordinated and integrated care.

For example, we know that the care ofpatients with long term conditions isnot as good as it could be and doesnot always meet recommendedguidelines. Taking diabetes as anexample, the National ServiceFramework recommends that patientswith diabetes should agree to a careplan to manage their conditions, as thebest results are achieved by:

• patients engaged in their own careand empowered to manage itthemselves or with the help of carers

• organised diabetes teams thatactively seek out people to ensurethat they get the best care

• partnerships between people withdiabetes and health and social careprofessionals to solve problems andplan care.

However, despite this guidance weknow from a 2006 HealthcareCommission survey of people withdiabetes that nationally less than 50%of people actually have an agreed careplan to manage their diabetes.

In terms of people with serious mentalhealth problems, 2007 HealthcareCommission survey reported that 25%

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are still not involved in drawing up theircare plan.

And looking across a range of longterm conditions – cardiovasculardisease, diabetes, dementia, COPD –some initial analysis by the Departmentof Public Health and Epidemiology atthe University of Birmingham suggeststhat less than 50% of patients eligiblefor treatment were receiving optimaltreatment for their condition.11

NEXT STEPSI believe the emerging picture is clear.Although some progress has beenmade, we can do much better indelivering the most effective care andoutcomes for patients.

Locally, the eight clinical pathwaygroups in each SHA region, describedin chapter 3, will consider how toimprove effectiveness in each pathwayin the second part of this Review.

Nationally, I believe we should focus onfacilitating innovation and on creatinga clear quality framework forhealthcare.

Innovation

Since the creation of the NHS,innovations in pharmaceuticals,medical devices and clinical care haveimproved the quality of patients’ lives.

But the NHS does not always makebest use of innovation. While therehave been increases in research anddevelopment funding, including therecent commitment to invest£15 billion over the next decade formedical research, and good progressin the uptake of clinically and cost-effective innovative technologiesappraised by NICE, more needs tobe done.

Despite some excellent work takingplace locally, there remains somereluctance within the NHS to adoptnew products and procedures. Forexample, my team and I performed thefirst colorectal keyhole bowel operationin the early 1990s in London. Butacross the NHS we are still well behindother European countries in the uptakeof this technique. The NHS needs tomove away from cost containmentand seek to harness innovation.To encourage this change in culture,there needs to be betterdemonstration of the benefits ofinnovation in terms of improved safety,effectiveness, personalisation, fairnessand value.

A new Health Innovation Council (HIC)will be established to act as theoverarching guardian for innovationfrom discovery through to adoption,holding the Department of Health andthe NHS to account for taking upinnovation and helping overcome

11 Harrison W, Marshall T, Singh D and Tennant R, The Effectiveness of healthcare systems in the UK – scoping study,Department of Public Health and Epidemiology and HSMC University of Birmingham, July 2006.

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barriers to doing so. Organisationsincluding NICE, the National Institutefor Health Research and the NHSInstitute for Innovation andImprovement will have key roles toplay and will be members of the HIC.

Linked to this, we need to think abouthow we can best bring togetherworld-class research, teaching andpatient care to encourage innovationand deliver exemplary care for patients.The concept of Academic HealthSciences Centres (AHSCs), which dojust this, will be rolled out in majorteaching centres across the country.

A clear quality framework

A key part of providing more effectivecare is being able to assess whatclinicians do so we can compare ourperformance with others. And patientsshould be able to see this informationbefore choosing where to be treated.

There is a wealth of informationalready available but it is not normallydirectly comparable and notbenchmarked in a systematic way. Forexample, while I record the clinicaloutcomes of the surgery I undertake,the data is not regularly benchmarkedagainst that of other surgeons carryingout similar work. There are individualexamples of excellent practice, such assome clinical audits, but these are

isolated examples.This is a significanthindrance to progress.

Establishing a clear framework andstandard ways to measure results willallow us to demonstrate the highquality of what we do, and identifywhat is needed to sustain and improvethat high quality. Any framework willneed to be comprehensive, rootedfirmly in the recurring questions abouttheir care that people tell us are at theforefront of their minds, but alsoscientifically valid and clinically relevant.It could be useful to build on recentadvances in measuring outcomes asassessed by patients themselves, andmake these patient-reported outcomemeasures a stronger part of ourapproach to clinical quality.

I have asked the Government’s ChiefMedical Officer, Professor Sir LiamDonaldson, to develop a standardquality framework and proposals forsystematic measurement against thisframework. I have asked ProfessorSir Bruce Keogh, the NHS MedicalDirector, to advise on how best toimplement it within the NHS.

Despite some excellent work taking place locally, thereremains some reluctance within the NHS to adopt newproducts and procedures

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VVIISSIIOONNA safe NHS must be as safe asit possibly can be, giving

patients and thepublic theconfidence theyneed in the carethey receive.

AA SSAAFFEE NNHHSSMMAATTTTEERRSS TTOO PPEEOOPPLLEE

Safety should be the first priorityof every NHS organisation. People

rightly expect to receive the safestpossible care and to be confident thatthis will be the case.

At the consultative event I attended inSeptember, I heard patients and thepublic voice their concerns about safety.They wanted the places where they gofor care to be clean, safe environmentswhere the risks of infection areminimised. They felt there should berigorous attention to cleanliness inparticular. In a study by the NPSA in2007, 71% of patients wanted to beinvolved with daily hand hygienepractice in hospital. Some 82% of thoseat the consultative events wantedinformation on infection rates whenchoosing which hospital to go to.

And staff agree that it is important.

WWHHEERREE WWEE AARREE NNOOWWSignificant progress has been madetowards improving safety in the NHS.The report An Organisation with aMemory (2000) brought the problem

of unsafe care to national attention forthe first time in the UK.

Since then, the NPSA has beenestablished, along with independentregulation underpinned by improvedclinical governance. When errors occurthey are investigated, lessons learnedand systems changed. We are about toembark on a new chapter of thisjourney. The recent report Safety First(2006) set out a national blueprint forpatient safety and has led to a freshapproach by the NPSA.

The National Reporting and LearningSystem has shown that healthcareprofessionals will report adverse events– there have been rapidly increasingnumbers of incidents reported in thelast three years. The objective is tocapture and report patient safetyincidents and promote learning andawareness in order to reduce harm topatients.

We also need to extend localaccountability for all aspects of safecare. Local patient safety action teamswill be responsible for encouragingreporting of errors, investigation ofincidents and ensuring local learning.

One area of safety practice ofparticular concern to patients is thecontrol of HCAI. International datashows that this is a shared problem.

Tackling MRSA has therefore been apriority for patients, the public andNHS staff. Action has been taken over

A safe NHS

A safe N

HS

7

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recent years, as a result of whichMRSA infection rates are coming down(although there is variation in progressbetween localities).

During this time, there has been anincreasing focus on C. difficile.Mandatory surveillance of C. difficilewas introduced in 2004 and specificinterventions to combat C. difficilehave been added to the widely usedSaving Lives delivery programme.

SSCCOOPPEE TTOO IIMMPPRROOVVEE Tackling safety issues, cleanliness andinfection control is the responsibility ofeveryone who comes into contact withthe NHS – from visitors to managers tonurses to surgeons. I believe we mustdo more to develop a culture of safety,and in some cases staff have told methat they need more powers andgreater authority to tackle these issues.A local focus is crucial – the problemcannot be addressed by centraldirection.

In the last few months, more actionhas been announced to tackle HCAI.These actions are designed both toimprove patients confidence in thesafety of their care and also to tacklethe root causes of infection. TheGovernment has:

• introduced a ‘bare below the elbows’dress code to improve the quality ofhand washing

• released new guidance on isolatinginfected patients

Prevalence ofHCAI

USA 5–10%Australia 6%Norway 7%England 8.3%Denmark 8%France 6–10%Netherlands 7%Spain 8%

Incidence ofMRSAbacteraemiasper 100,000patient days

Netherlands 0.35Germany 3.29Spain 6.00Italy 6.44Greece 7.36UK 9.56France 11.79Portugal 17.58

These tables are based on internationalsurveillance data and other available evidence

12 Health Protection Agency

2,500

2,700

2,900

3,100

3,300

3,500

3,700

3,900

Apr –Sep 03

Apr –Sep 04

Oct 03 –Mar 04

Oct 04 –Mar 05

Apr –Sep 05

Oct 05 –Mar 06

Apr –Sep 06

Oct 06 –Mar 07

MRSA bloodstream infections by six-monthperiod (April 2003 – March 2007)12

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• extended the NPSA’s cleanyourhandscampaign to care settings outsidehospitals

• announced that the forthcoming Billwill introduce a new legalrequirement on chief executives,backed by fines, to report MRSAbloodstream infections and C. difficileinfections to the Health ProtectionAgency

• set out plans for a deep clean of allhospital wards as part of the drive fora culture of cleanliness.

• made £50 million available for SHADirectors of Nursing to spend ontackling HCAI

• doubled the size of the expertimprovement team

• announced quarterly reporting totrust boards by matrons and clinicaldirectors on infection control andcleanliness

NNEEXXTT SSTTEEPPSS

There will now be further action tobuild on this. We will:

• use the Bill to give a new health andadult social care regulator toughpowers, backed by fines, to inspect,investigate and intervene wherehospitals are failing to meet hygieneand infection control standards

We should build on the action we have taken already totackle HCAI by going even further

Cleanliness isn’t just aboutinfection. It also gives animpression to patients sothat they can be confidentabout the standard of carethey are going to receive.

(South East Coast – consultativeevent)

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• introduce annual infection controlinspections of all acute trusts usingteams of specialist inspectors

• introduce MRSA screening for allelective admissions next year, and forall emergency admissions as soon aspracticable within the next 3 years.

• look into ways of building financialpenalties or rewards into thecommissioning process linked toproviders’ performance in terms ofHCAIs and cleanliness.

And we must empower staff,particularly nurses. For this reason,I have asked the Chief Nursing Officer,Professor Christine Beasley, to takeforward work as part of the Review todevelop a clear plan and guidance forthe NHS which increases the powers oflocal staff. This means empoweringmatrons to:

• report any concerns they have onhygiene direct to the new regulator

• order additional cleaning

I also believe we should build on theNational Reporting and LearningSystem, responding to feedback fromthe service, and support the NPSA inestablishing a single point of access forfrontline workers to report safetyincidents: Patient Safety Direct. Thiswould use email, telephone and lettersto streamline the reporting process,providing a quicker and moresystematic service 24 hours a day.

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LOCAL CHANGERealising our vision for a worldclass NHS means working

differently. If we aregenuinely to makethe most of thetalents of staff andrespond to patients’expectations, we

need to empowerpatients and give health

and social care staff greaterflexibility to respond and lead.

NEW STANDARDS FOR LOCALCHANGEAt the same time, I have heard duringthe first part of the Review that wherechange does go ahead, it does notalways happen as transparently as itshould. We need to reassure patientsand the public that change is necessaryand that it will improve the care theyreceive. I believe we can and should domore now to improve this process.

We should be clear from the outsetthat no major service change shouldhappen except on the basis of needand sound clinical evidence. Specificallywe will:

• raise the standard of evidence weexpect before change takes place –we will publish by the end of this yeara set of guidelines for how local areasshould undertake changes to NHSservices. These will be founded onthe principles and recommendationsset out in the Carruthers Review(February 2007). They will make clearthat change should only be initiatedwhen there is a clear and strongclinical basis for doing so; and thatconsultation should proceed onlywhere there is effective and earlyengagement with the public, clearevidence of improved outcomes forpatients, and resources available toenable new facilities to openalongside old ones closing

• ensure that local decision-makingprocesses are subject to greaterpublic and clinical scrutiny includingby ensuring that the local case forchange is led by clinicians, and issubjected to independent clinicalassessment prior to consultation –through the Office of GovernmentCommerce’s Gateway review processwhose main findings andrecommendations will be published.The public should be reassured thatthe NHS will not pursue changes thathave not been verified as safer andof a higher quality

A locallyaccountable NHS

If we are genuinely to make the most of the talents of NHSstaff and respond to patients’ expectations, we need toempower health and social care staff locally

A locally accountable N

HS

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• streamline the process – I haveobserved that the process ofconsultation is often too protracted,delaying decisions unnecessarily.There are currently few timescales forany part of the reconfigurationprocess other than the formal publicconsultation stage (minimum 12weeks). We will therefore publish forconsultation options for streamliningthe reconfiguration process, includingintroducing clear timescales for allkey stages

• improve the evidence base – anational clinical evidence base will becreated, housing what local, nationaland international clinicians believe tobe the best available evidence aboutclinical practice, pathways and

models of care and innovations. Thiswill be available to commissioners,practitioners, patients and the publicalike. We will work with the relevantbodies, such as NICE, the NationalLibrary for Health the new HealthInnovation Council and theIndependent Reconfiguration Panel(IRP) to take this forward.

SUPPORTING ACTIONThe second stage of my Review willalso focus on supporting the frontlineNHS in responding to these challenges.To understand what is required to dothis, I have held discussions during thefirst part of this Review with a widerange of stakeholders – includingprofessional bodies, trade unions andvoluntary sector organisations – and

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identified a number of areas on whichaction is needed. Those areas include:

• workforce planning, education andtraining

• leadership

• information to support excellence

• enabling systems and processes

• the case for an NHS Constitution.

I will be using the second part of thisreview to work with the senior NHSleadership team – clinicians andmanagers – to bring together expertsfrom this country and abroad todiscuss the key issues in more detailand identify the best way in each caseto support change to happen locally. Iwant this work to involve professionalbodies, trade unions, voluntary sectororganisations and other partners.

To ensure that the NHS benefits fromthe best available advice, I will also becommissioning research, analysis andcontributions from a range oforganisations, in this country andabroad.

Workforce planning, education andtraining

The NHS currently employs over 1.3million people – 70% of its costs arelinked to staffing. The NHS spends over£4 billion annually on training anddeveloping its staff so they can providethe best quality care. Yet despite anincreasing NHS budget, education andtraining expenditure has not increasedas much as planned in the last year.This has often affected those whoneeded it most – the staff who havebenefited least from developmentopportunities. We also know thatcommissioning of training places hasnot always matched commissioning ofservices. We therefore need to domore to grasp the potential ofeducation as a lever for serviceimprovement.

Despite the highly publicised problemswith the Medical Training ApplicationService (MTAS) recruitment system,I believe that the principles of theModernising Medical Careers (MMC)programme developed with the

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professional bodies and regulators aresound. It is the implementation thathas fallen so far short.

But overall, our approach to workforceplanning and the commissioning ofeducation and training needs anoverhaul, so that we can avoid anyrepetition of the problem where manyNHS-trained physiotherapists whograduated last year were not able tofind posts in the NHS despiterehabilitation after illness (such asstroke) being vital to the recovery ofhundreds of thousands of NHSpatients.

And we need to look at the content ofcurricula to ensure that they arealigned with the care our vision isintended to deliver.

Workforce planning needs to be moreevidently and consistently linked withnew models of care and with financialand service planning at all levels in thesystem. Education and training providersalso need to be more involved andforward looking.

We need to strengthen education andtraining commissioning so that trainingfor all staff delivers the skills andcompetencies required to meet staffand patient expectations. We shoulddevelop robust quality-assessment

tools to ensure we are getting the rightquality of education, not just the rightquantity.

Leadership

The essence of clinical leadership is tomotivate, to inspire, to promote thevalues of the NHS, to empower and tocreate a consistent focus on the needsof the patients being served.Leadership is necessary not just tomaintain high standards of care but totransform services to achieve evenhigher levels of excellence.

I often hear clinicians say that they feelconstrained and undervalued bymanagers, and this also appliesbetween different clinical groups. But itis also true that managers sometimessee clinicians as stubborn and slow tochange. Most importantly, however,recent research (What Matters to Staff,2007) has demonstrated just how muchclinicians, managers and other staffwant to collaborate on improving localservices. There is evidence that wherethis is already happening, patient andstaff satisfaction is higher.

The challenge now is to accelerate ourprogress. I will ask the NHS ChiefExecutive, David Nicholson, to convenea national working group to identifyactions we can take. Included in this

Our approach to workforce planning and the commissioningof education and training needs an overhaul

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group will be professional andrepresentative bodies. It will drawon best NHS and international

practices. I will askthem to considerhow to put thebusiness of care atthe heart of whatlocal NHS boards do

and, specifically to:

• define what excellentleadership looks like, includingcollaborative leadership

• develop a strategy for healthleadership development, includingresearch

• examine how leadershipdevelopment can be built into formaland informal education and trainingfor all professional groups, and rolemodels identified, building onexisting work

• consider how to identify andencourage healthcare professionalsto take up leadership roles as part ofnormal career paths.

Information to support excellence

All modern organisations servingconsumers rely on high qualityinformation to provide consumers with

choice, to assess progress, to cementaccountability and to evaluate theinput of new policies or programmes.

The NHS has a great deal of data, buta paucity of information. Much of theinformation we do have is available tolimited numbers of people, is ofteninconsistent with that held elsewhere,and is frequently not available at thepoint of need.

The NHS’s recent investment intechnology has created theopportunity to make a step-change.The national infrastructure establishedby the National Programme forInformation Technology has connectedevery hospital and GP surgery to acommon secure network. Cliniciansshould benefit from theimplementation of digital access toX-rays and scans – Picture Archivingand Communications System (PACS).But I believe more work is now neededto ensure that the Connecting forHealth programme delivers real clinicalbenefits, and I will be considering inthe second stage of my Review howbest to achieve this.

Enabling systems and processes

The NHS is perhaps two-thirds of theway through its reform programme setout in 2000 and 2002. In my visits

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across the NHS I have detected littleenthusiasm for doing somethingcompletely different; instead themajority opinion is that the currentreforms should be seen through totheir conclusion. I agree. A morepersonalised NHS requires services thatare locally designed and can adaptquickly to patients’ needs. In turn thatmeans that if we are to have worldclass services across the board, thenwe need world class commissioning.PCTs working with practice-basedcommissioners and local authorities willneed to commission services based onthe models of care that the localclinical pathway groups devise.

Commissioners need to look at bestpractice across the globe and ensurethat a range of independent andcommercial skills are adopted orbrought in, where they can improvepopulation health and healthcare.Given the variation in NHScommissioning skills currently on offer,in my view – and that of theGovernment – that needs to meanextensive use within every SHA of thenew Framework for procuring ExternalSupport for Commissioners (FESC).

The case for an NHS Constitution

The way the NHS is run has evolved tomeet today’s challenges. There isalready much less top-downintervention, with NHS foundationtrusts much more free to innovatelocally, and PCTs able to decide onservice priorities to a greater degreethan before.

While there is a consensus that theshape and delivery of local servicesshould be determined locally, wherethis is not possible, people want a clearand transparent process for arbitrationand decision making. They feel thatwithout this clarity people cannot beheld to account properly for thedecisions they do take.

In my terms of reference, the PrimeMinister and the Secretary of State saidthat, at the end of the Review, adecision will be taken on whetherthere is a case for an NHSConstitution, as part of a new andenduring settlement for the NHS as itapproaches its 60th birthday. Theobjective would be to enshrine thevalues of the NHS and increase localaccountability to patients and public.

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The Secretary of State and I have askedthe NHS Chief Executive to establishand chair a national working group ofexperts to consider the scope, form andcontents of an NHS Constitution orsettlement, in particular how it might:

• help secure the enduring principlesand fundamental values of the NHS,based on evidence of what mattersto our patients, the public and staff

• establish a stronger framework ofresponsibility, accountability andlegitimacy for decision making withinthe service, both nationally and locallyincluding in PCTs and NHS foundationtrusts

• establish the responsibilities of allorganisations who work for NHSpatients

• include an open and accountableprocess for arbitration and decisionmaking where decisions on theshape and delivery of local servicescannot be resolved locally

• embed a stronger focus on rightsand responsibilities for patients, thepublic and staff, based on evidenceof what matters

A stronger focus on rights and responsibilities for patients,the public and staff, based on evidence of what matters

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• set out a right of engagement forpatients and staff coveringconsultation, independent assuranceand rights of redress

• strengthen the opportunity to workin partnership with other agencies toimprove access and the integration ofcare

• review the process for NHSappointments, in line with theGovernance of Britain green paper.

This work will be underpinned by whatour patients, staff and the public tell usover the coming months. I have beendelighted by the enthusiasm thatpeople have shown for the Review sofar – and it is clear that there is anappetite for more engagement as thiswork progresses. Whether we devisean NHS Constitution or not, part of myresponsibility is to ensure that everyonewho wants to can feed into thatprocess and have a real opportunity toinfluence the shape of our NHS for thenext decade.

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I want people across the country –patients, the public and staff whereverthey are working in the health andsocial care system – to discuss thisreport and to get involved in shapinga world class NHS. I encourage youto discuss, deliberate and examinethe proposals and let me knowyour comments.

Engagement will be locally led; Ienvisage many more discussions takingplace up and down the country, similarto the events we held nationwide inSeptember.

The Review website,www.nhs.uk/ournhs, containsinformation about the Review andupdates about what is happening inyour area. It will shortly contain anonline resource pack to support yourdiscussions locally; the materialincludes tailored agendas for a full-dayand half-day event, standardisedfeedback forms to record the outputsfrom your discussions and supportingdocuments.

An online questionnaire will be madeavailable soon, downloadable from thesite, and I encourage you to share itamong your friends, family, carers,

neighbours, colleagues and peers.Hard copies of the questionnaire areavailable on demand from:

DH Publication OrderlinePO Box 777London SE1 6XH

email: dh@prolog.uk.comTel: 08701 555455Fax: 01623 724524

I have also arranged for a number ofnew forums and groups to be createdto enable people to contribute theirviews. The many organisations involvedin health and social care will becontinuing their normal processes fordialogue with stakeholders as well.

If you are unable to hold or attend alocal event, or cannot contribute to thequestionnaire, I still want to hear yourviews. You can emailournhs@dh.gsi.gov.uk or write to meat the Department of Health, and I willensure that your viewsare taken into account.

How to getinvolved

I want people across the country – patients, the public andstaff wherever they are working in the health and social caresystem – to discuss this report and to get involved in shapinga world class NHS

DH INFORMATION READER BOX

Policy EstatesHR/Workforce CommissioningManagement IM & TPlanning/ FinanceClinical Social Care/Partnership Working

Document purpose Gathering INFORMATION

ROCR ref: Gateway ref: 8857

Title NHS Next Stage Review Interim Report

Author Professor Lord Darzi

Publication date 04 Oct 2007

Target audience PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Foundation TrustCEs, Medical Directors, Directors of PH, Directors of Nursing, PCTPEC Chairs, NHS Trust Board Chairs, Special HA CEs, Directors of HR,Directors of Finance, Allied Health Professionals, GPs,Communications Leads, Emergency Care Leads, Local AuthorityCEs, Directors of Adult SSs, Directors of Children’s SSs, Voluntaryand Independent Sector Organisations

Circulation list (See above)

Description Interim report by Lord Darzi on the NHS Next Stage Review

Cross reference N/A

Superseded documents N/A

Action required N/A

Timing N/A

Contact details NHS Next Stage Review TeamRoom 524A, Richmond House,79 Whitehall, LondonSW1A 2NS020 7210 3000Email: ournhs@dh.gsi.ukhttp://www.nhs.uk/ournhs

For recipient’s use

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NHS NEXT STAGE REVIEW

Interim reportOctober 2007

© Crown copyright 2007

Produced by COI for the Department of Health283411 1p 5k Sep 07 (CWP)

If you require further copies of this title quote 283411/Our NHS Our Future and contact:

DH Publications OrderlinePO Box 777, London SE1 6XH

Email: dh@prolog.uk.comTel: 08701 555 455Fax: 01623 724 524

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