East of EnglandEast MidlandsLondonNorth EastNorth WestSouth East CoastSouth CentralSouth WestWest MidlandsYorkshire and the HumberHigh Quality Care For AllNHS Next Stage Review Final Report
High Quality Care For AllNHS Next Stage Review Final ReportPresented to Parliament by the Secretary of State for Health by Command of Her MajestyJune 2008CM 7432£13.90
© Crown Copyright 2008The text in this document (excluding the Royal Arms and other departmental or agency logos) may be reproduced free of charge in any format or medium providing it is reproduced accurately and not used in a misleading context.The material must be acknowledged as Crown copyright and the title of the document specified.Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned.For any other use of this material please write to Office of Public Sector Information, Information Policy Team, Kew, Richmond, Surrey TW9 4DU or e-mail: firstname.lastname@example.org
Gateway reference: 10106
IntroductionTHE NHS NEXT STAGE REVIEW CLINICAL LEADS IN THE 10 STRATEGICHEALTH AUTHORITIESIn previous reviews of the NHS,frontline staff have been on the fringesor bystanders. This Review has beendifferent. We and our colleagues in theNHS have been at its core. There hasbeen an unprecedented opportunity forhealth and social care professionals toreview the best available evidence, todiscuss priorities with patients and thepublic, and develop compelling sharedvisions for our local NHS.Through this Review, the NHS hascreated its own ambitious visions forthe future of health and healthcare.This marks a real change in therelationship between the frontline NHSand the centre. Lord Darzi and theDepartment of Health have focused onsupporting the improvements we wantto make. This report will enable the localNHS to achieve what matters to us, topatients and to the public – improvedhealth and high quality care for all.Dr James CaveBSc (Hons) MBBS DRCOG FRCGPNHS South Central Clinical LeadGeneral Practitioner, Berkshire WestPrimary Care TrustProfessor Matthew CookePhD FCEM FRCS (Ed)NHS West Midlands Clinical LeadProfessor of Emergency Medicine, Heartof England NHS Foundation Trusts andWarwick Medical SchoolSir Cyril ChantlerMA MD FRCP FRCPH FMedSciNHS London Clinical LeadChairman, Great Ormond Street Hospitalfor Children NHS TrustProfessor Peter KellyBSc PhD CStat FFPHNHS North East Clinical LeadExecutive Director of Public Health forTees Primary Care Trusts
High Quality Care For All – NHS Next Stage Review Final Report1Professor Mayur Lakhani CBEFRCGP FRCPNHS East Midlands Joint Clinical LeadMedical Director, NHS East MidlandsStrategic Health AuthorityDr Jonathan P SheffieldMBChB FRCPathNHS South West Clinical LeadMedical Director, University HospitalsBristol NHS Foundation TrustDr Kathy McLeanMBChB FRCPNHS East Midlands Joint Clinical LeadMedical Director, Derby Hospitals NHSFoundation TrustMr Edward Palfrey MA MB BChir FRCS FRCS(Ed)NHS South East Coast Clinical LeadMedical Director, Frimley Park HospitalNHS Foundation TrustProfessor Christopher L WelshMA MB MChir FRCS FFOM (Hon)NHS Yorkshire and the HumberClinical LeadMedical Director, Yorkshire and theHumber Strategic Health Authorityand Chief Operating Officer, SheffieldTeaching Hospitals NHS Foundation TrustDr Robert WinterMA MD FRCPNHS East of England Clinical LeadMedical Director, Cambridge UniversityHospitals NHS Foundation TrustDr Steve RyanMBChB MDNHS North West Clinical LeadMedical Director Royal LiverpoolChildren’s NHS Trust
PrefaceBy the Prime MinisterThe National Health Service is not justa great institution but a unique andvery British expression of an ideal –that healthcare is not a privilege to bepurchased but a moral right secured for all.For 60 years it has carried the support ofthe British people because it speaks to ourvalues of fairness and opportunity for alland because it is always there for us whenwe are most vulnerable and in need.That is why it is right that we should seekto renew the NHS for the 21 st century.To meet the rising aspirations of thepublic, the changing burdens of diseaseand to ensure that the very latest,personalised healthcare is available to allof us, not just those able to pay.Over the last 10 years we haveimproved the basic standards of theNHS. In 2000, the NHS Plan set out totackle the challenges which chronicunderinvestment had created. Since thenwe have invested in 80,000 more nursesand 38,000 more doctors, including5,000 more GPs. Access to care hasimproved dramatically, and outcomeshave improved as a result: 238,000 liveshave been saved in the last 11 years asa result of significant improvements incancer and heart disease survival ratesin particular.This report builds on those reformsand will, I believe, have an even moreprofound affect on NHS services and ourexperience of them. If the challenge10 years ago was capacity, the challengetoday is to drive improvements inthe quality of care. We need a morepersonalised NHS, responsive to each ofus as individuals, focused on prevention,better equipped to keep us healthy andcapable of giving us real control and realchoices over our care and our lives.Lord Darzi’s report is a tremendousopportunity to build an NHS thatprovides truly world class services forall. It requires Government to be seriousabout reform, committed to trustingfrontline staff and ready to invest in newservices and new ways of deliveringservices. It is a bold vision for an NHSwhich is among the best healthcaresystems in the world – a once in ageneration opportunity that we owe itto ourselves and our families to take.I would like to thank Lord Darzi andthe thousands of those who havebeen involved in the review locally andnationally for their contributions. As aGovernment the renewal of the NHSmust be one of our very highest prioritiesand we will rise to the challenge youhave set us.Gordon BrownPrime Minister
High Quality Care For All – NHS Next Stage Review Final Report3ForewordBy the Secretary of State for HealthOn its 60 th anniversary, the NHS is ingood health.The NHS touches our lives at timesof basic human need, when care andcompassion are what matter most.Over the past 60 years, it has been avital friend to millions of people, sharingtheir joy and comforting their sorrow.The service continues to be availableto everyone, free at the point of need.One million people are seen or treatedevery 36 hours, and nine out of 10people see their family doctor in anygiven year. In 2008, the NHS will carryout a million more operations than it didjust 10 years ago.Over the past decade, the NHS budgethas trebled. It employs a third morepeople than it did – more doctors, morenurses, delivering better care for patients.We have invested in new facilities andadvanced equipment – last autumn weannounced an additional £250 million toimprove access to GP services includingover 100 new practices in the mostdeprived areas of the country.The Prime Minister, Chancellor and Iasked Lord Darzi to lead this Reviewworking in partnership with patients,frontline staff and the public to developa vision of a service fit for the 21 stcentury. He has succeeded. The strengthof this Review has been the 2,000frontline clinicians and other local healthand social care staff who have led theprocess, with thousands more staff,patients and members of the publicinvolved across the country.The NHS already delivers high qualitycare to patients in many respects.The NHS Next Stage Review makes acompelling case that it can deliver highquality care for patients in all respects.It is only because of the investment andreform of the past decade that this isnow possible.We are also launching an NHSConstitution for consultation. The NHS isas much a social movement as a healthservice. That is why it is so vital to secureits founding principles and set out therights and responsibilities of patients,public and staff.Lord Darzi has led this Reviewmagnificently, bringing to bear hugepersonal credibility and integrity. I thankhim and the thousands of people thathave worked to create this Reviewlocally and nationally. It is testament towhat we can achieve when everyone inthe NHS works together for the benefitof patients.The Rt Hon Alan Johnson MPSecretary of State for Health
High Quality Care For All – NHS Next Stage Review Final Report5ContentsSummary letter: Our NHS – Secured today for future generationsAn NHS that gives patients and the public more information and choice,works in partnership and has quality of care at its heart1 Change – locally-led, patient-centred and clinically drivenA nationwide process – the core of the NHS Next Stage Review2 Changes in healthcare and societyThe challenges facing the NHS in the 21st century3 High quality care for patients and the publicAn NHS that works in partnership to prevent ill health, providingcare that is personal, effective and safe4 Quality at the heart of everything we doHigh quality care throughout the NHS5 Freedom to focus on qualityPutting frontline staff in control6 High quality work in the NHSSupporting NHS staff to deliver high quality care7 The first NHS ConstitutionSecured today for future generations8 ImplementationMaintaining the momentum71624324658687682
High Quality Care For All – NHS Next Stage Review Final Report7Summary LetterSummary letterOur NHS – Secured today for future generationsby Lord DarziAn NHS that gives patients and thepublic more information and choice,works in partnership and has quality ofcare at its heart.Dear Prime Minister, Chancellor ofthe Exchequer, and Secretary of Statefor Health,This year the NHS is 60 years old.We are paying tribute to a servicefounded in adversity, from which wereestablished enduring principles of equalaccess for all based on need and notability to pay. We are celebrating anational institution that has made animmeasurable difference to millions ofpeople’s lives across the country.Quite simply, the NHS is there when weneed it most. It provides round the clock,compassionate care and comfort. It playsa vital role in ensuring that as many of usas possible can enjoy good health for aslong as possible – one of the things thatmatters most to us and to our family andfriends.The journey so farI know the journey we have all beenon from my own experience as anNHS clinician working in partnershipwith professional colleagues acrossthe service.I used to be the only colo-rectal surgeonin my hospital; today I am a member ofa team of four surgeons, working in anetwork that reaches out into primarycare. Ten years ago, we had one parttimestoma nurse. Today we have twofull-time stoma nurses, two specialistnurses and a nurse consultant.Ten years ago, my patients wouldsometimes wait over a year fortreatment, and now they wait just afew weeks – and even less if cancer issuspected. My patients are treated usingkeyhole surgery enabling them to leavehospital in days rather than weeks.My team’s conversations about qualitytake place in weekly multidisciplinarymeetings rather than in corridors.Together, these changes have meantreal improvements for patients.I have seen for myself the NHS gettingbetter, and I have heard similar storiesfrom other clinical teams throughout thecountry over the course of this Review.These achievements were enabled bythe investment of extra resources, 1 bygiving freedom to the frontline throughNHS foundation trusts, and by ensuringmore funding followed patient choices.They were delivered by the dedicationand hard work of NHS staff who weredetermined to improve services forpatients and the public.1 In 1996/7, the budget for the NHS in England was£33 billion; in 2008/9 it is £96 billion.
8 Summary letterThe next stage of the journeyMy career is dedicated to improvingcontinuously the quality of care weprovide for patients. This is what inspiresme and my professional colleagues, andit has been the guiding principle for thisReview. We need to continue the NHSjourney of improvements and movefrom an NHS that has rightly focused onincreasing the quantity of care to onethat focuses on improving the qualityof care.There is still much more to do to achievethis. I have continued my clinical practicewhile leading the Review nationally.I have seen and treated patients everyweek. Maintaining that personalconnection with patients has helped meunderstand the improvements we stillneed to make. It has driven me to focusthis Review on practical action.It is because of this that I have beenjoined in this Review by 2,000 cliniciansand other health and social careprofessionals from every NHS region inEngland. Their efforts, in considering thebest available evidence and in setting outtheir own visions for high quality services(described in Chapter 1), have been thecentrepiece of this process.Their visions – developed in discussionwith patients, carers and members ofthe general public – set out bold andambitious plans. I am excited by thelocal leadership they demonstrate andthe commitment of all those who havebeen involved.In developing the visions, the NHS hashad to face up to significant variationsin the quality of care that is provided.Tackling this will be our first priority.The NHS needs to be flexible to respondto the needs of local communities,but people need to be confident thatstandards are high across the board.Delivering the visions will mean tacklinghead on those variations in the qualityof care and giving patients moreinformation and choice. The messagethey send is that the programme ofreform that has been put in place hasbeen unevenly applied and can gomuch further.We also need to accelerate change forother reasons. Chapter 2 describes thechanges facing society and healthcaresystems around the world. It sets outhow the NHS in the 21 st century facesa particular set of challenges, which Iwould summarise as: rising expectations;demand driven by demographics;the continuing development of our‘information society’; advances intreatments; the changing nature ofdisease; and changing expectationsof the health workplace. These arechallenges we cannot avoid. The NHSshould anticipate and respond to thechallenges of the future.My conclusions, and the measuresdescribed in this report, focus on howwe can accelerate the changes thatfrontline staff want to make to meetthose challenges, whilst continuing toraise standards.The vision this report sets out is of anNHS that gives patients and the publicmore information and choice, works inpartnership and has quality of care atits heart – quality defined as clinically
High Quality Care For All – NHS Next Stage Review Final Report9effective, personal and safe. It will seethe NHS deliver high quality care for allusers of services in all aspects, not justsome. I set out below the key steps wemust take to deliver this vision.High quality care for patients andthe publicThroughout this Review, I have heardclearly and consistently that people wanta greater degree of control and influenceover their health and healthcare. Ifanything, this is even more important forthose who for a variety of reasons findit harder to seek out services or makethemselves heard.Personalising services means makingservices fit for everyone’s needs, notjust those of the people who make theloudest demands. When they need it,all patients want care that is personalto them. 2 That includes those peopletraditionally less likely to seek help orwho find themselves discriminatedagainst in some way. The visionspublished in each NHS region makeclear that more support is needed forall people to help them stay healthyand particularly to improve the healthof those most in need. Chapter 3explains how we will do this including byintroducing new measures to:Create an NHS that helps peopleto stay healthy. For the NHS to besustainable in the 21 st century it needsto focus on improving health as well astreating sickness. This is not about the‘nanny state’. As a clinician, I believe that2 Opinion Leader Research, Key findings of 18September 2007 Our NHS, Our Future nationwideconsultative event.the NHS has a responsibility to promotegood health as well as tackle illness.Achieving this goal requires the NHSto work in partnership with the manyother agencies that also seek to promotehealth. Much progress on closer workinghas been made in recent years. In linewith my terms of reference, 3 this reportsfocuses on what the NHS can do toimprove the prevention of ill health.The immediate steps identified by thisReview are:• Every primary care trust willcommission comprehensivewellbeing and preventionservices, in partnership with localauthorities, with the servicesoffered personalised to meetthe specific needs of their localpopulations. Our efforts must befocused on six key goals: tacklingobesity, reducing alcohol harm,treating drug addiction, reducingsmoking rates, improving sexual healthand improving mental health.• A Coalition for Better Health, witha set of new voluntary agreementsbetween the Government, privateand third sector organisationson actions to improve healthoutcomes. Focused initially oncombatting obesity, the Coalitionwill be based on agreements toensure healthier food, to get morepeople more physically active, and toencourage companies to invest morein the health of their workforce.3 Terms of Reference available atwww.ournhs.nhs.uk
10 Summary letter• Raised awareness of vascular riskassessment through a new ‘ReduceYour Risk’ campaign. As we rollout the new national programme ofvascular risk assessment for peopleaged between 40 and 74, we willraise awareness through a nationwide‘Reduce Your Risk’ campaign – helpingpeople to stay healthy and to knowwhen they need to get help.• Support for people to stay healthyat work. We will introduce integratedFit for Work services, to help peoplewho want to return to work but arestruggling with ill health to get backto appropriate work faster.• Support GPs to help individualsand their families stay healthy.We will work with world-leadingprofessionals and patient groups toimprove the Quality and OutcomesFramework to provide better incentivesfor maintaining good health as well asgood care.We will give patients more rights andcontrol over their own health and care.I have heard the need to give patientsmore information and choice to makethe system more responsive to theirpersonal needs. We will:• Extend choice of GP practice.Patients will have greater choice ofGP practice and better information tohelp them choose. We will developa fairer funding system, ensuringbetter rewards for GPs who provideresponsive, accessible and high qualityservices. The NHS Choices website willprovide more information about allprimary and community care services,so that people can make informedchoices.• Introduce a new right to choice inthe first NHS Constitution. The draftNHS Constitution includes rights tochoose both treatment and providersand to information on quality, so that,wherever it is relevant to them, patientsare able to make informed choices.• Ensure everyone with a long-termcondition has a personalised careplan. Care plans will be agreed by thepatient and a named professional andprovide a basis for the NHS and itspartners to organise services aroundthe needs of individuals.• Pilot personal health budgets.Learning from experience in social careand other health systems, personalhealth budgets will be piloted, givingindividuals and families greatercontrol over their own care, withclear safeguards. We will pilot directpayments where this makes mostsense for particular patients in certaincircumstances.• Guarantee patients access to themost clinically and cost effectivedrugs and treatments. All patientswill receive drugs and treatmentsapproved by the National Institute forHealth and Clinical Excellence (NICE)where the clinician recommends them.NICE appraisals processes will bespeeded up.
High Quality Care For All – NHS Next Stage Review Final Report11The common theme of these newmeasures for patients is improvingquality. It must be the basis of everythingwe do in the NHS.Quality at the heart of the NHSIn my career as a surgeon, I try to domy best to provide patients with highquality NHS care – just like hundredsof thousands of other staff. This hasbeen my guiding principle as I have ledthis Review.High quality care should be as safeand effective as possible, with patientstreated with compassion, dignity andrespect. As well as clinical quality andsafety, quality means care that is personalto each individual.As independent research has shown, 4the NHS has made good progress overthe past decade in improving the overallquality of care for patients. During thisperiod, improvements in quality werefocused primarily on waiting times,as basic acceptable standards of accessto A&E and secondary care wereestablished, and on staffing levels andphysical infrastructure.Today, with the NHS budget approaching£2 billion a week, more staff, andimprovements in the quality andavailability of information, quality can beat the heart of everything we do in theNHS. It means moving from high quality4 S Leatherman and K Sutherland, The Quest forQuality: Refining the NHS Reforms, NuffieldTrust, May 2008 and K Davis et al., Mirror, Mirroron the Wall: An international update on thecomparative performance of American healthcare,Commonwealth Fund, May 2007.care in some aspects to high quality carein all.We will raise standards. The visions setout for each NHS region and formed bypatients’ expectations are ambitious forwhat the NHS can achieve. Chapter 4 ofthis report sets out the measures that willenable us to meet these standards:• Getting the basics right first time,every time. We will continue to seekimprovements in safety and reductionsin healthcare associated infections.The Care Quality Commission will havenew enforcement powers. There willbe national campaigns to make careeven safer.• Independent quality standardsand clinical priority setting. NICEwill be expanded to set and approvemore independent quality standards.A new National Quality Board willoffer transparent advice to Ministerson what the priorities should be forclinical standard setting by NICE.• For the first time we willsystematically measure and publishinformation about the qualityof care from the frontline up.Measures will include patients’ ownviews on the success of their treatmentand the quality of their experiences.There will also be measures of safetyand clinical outcomes. All registeredhealthcare providers working for, or onbehalf of, the NHS will be required bylaw to publish ‘Quality Accounts’ justas they publish financial accounts.
12 Summary letter• Making funding for hospitalsthat treat NHS patients reflectthe quality of care that patientsreceive. For the first time, patients’own assessments of the success oftheir treatment and the quality of theirexperiences will have a direct impacton the way hospitals are funded.• For senior doctors, the currentClinical Excellence Awards Schemewill be strengthened, to reinforcequality improvement. New awards,and the renewal of existing awards,will become more conditional onclinical activity and quality indicators;and the Scheme will encourage andsupport clinical leadership of servicedelivery and innovation.• Easy access for NHS staff toinformation about high qualitycare. All NHS staff will have accessto a new NHS Evidence service wherethey will be able to get, through asingle web-based portal, authoritativeclinical and non-clinical evidence andbest practice.• Measures to ensure continuousimprovement in the quality ofprimary and community care. Wehave just completed our consultationon proposals to bring all GP practicesand dental practices within the scopeof the new health and adult socialcare regulator, the Care QualityCommission. 5 We will introduce a newstrategy for developing the Qualityand Outcomes Framework whichwill include an independent andtransparent process for developing andreviewing indicators. We will supportpractice accreditation schemes, likethat of the Royal College of GeneralPractitioners.• Developing new best practice tariffsfocused on areas for improvement.These will pay for best practice ratherthan average cost, meaning NHSorganisations will need to improve tokeep up.We will strengthen the involvement ofclinicians in decision making at everylevel of the NHS. As this Review hasshown, change is most likely to beeffective if it is led by clinicians. We willdo this by ensuring that:• Medical directors and qualityboards feature at regional andnational level. These will complementthe arrangements at PCT level that aredeveloping as part of the World ClassCommissioning programme.• Strategic plans for delivering thevisions will be published later thisyear by every primary care trust.Change will be based on the fiveprinciples I set out earlier this year inLeading Local Change. 6• There is clear local support forquality improvement. A new ‘QualityObservatory’ will be established inevery NHS region to inform localquality improvement efforts.5 Department of Health, The future regulation ofhealth and adult social in England, 25 March 2008.6 NHS Next Stage Review: Leading Local Change,Department of Health, May 2008.
High Quality Care For All – NHS Next Stage Review Final Report13We will foster a pioneering NHS.Throughout my career, in all the clinicalteams I have worked in, my colleaguesand I have challenged one another toimprove the way we provide care forpatients. Continuous advances in clinicalpractice mean the NHS constantly hasthe opportunity to improve. My reviewwill enable this through:• Introducing new responsibilities,funds and prizes to support andreward innovation. Strategic healthauthorities will have a new legal dutyto promote innovation. New fundsand prizes will be available to thelocal NHS.• Ensuring that clinically and costeffective innovation in medicinesand medical technologies isadopted. We will strengthen thehorizon scanning process for newmedicines in development, involvingindustry systematically to supportbetter forward planning and developways to measure uptake. For newmedical technologies, we will simplifythe pathway by which they passfrom development into wider use,and develop ways to benchmark andmonitor uptake.• Creating new partnershipsbetween the NHS, universitiesand industry. These ‘clusters’ willenable pioneering new treatments andmodels of care to be developed andthen delivered directly to patients.These changes will help the NHS toprovide high quality care across theboard. Throughout this Review, it hasbeen clear that high quality care cannotbe mandated from the centre – itrequires the unlocking of the talents offrontline staff.Working in partnership with staffI have heard some people claim thatthere is ‘change fatigue’ in the NHS.I understand that NHS staff are tired ofupheaval – when change is driven topdown.It is for this reason that I choseto make this Review primarily local, ledby clinicians and other staff working inthe NHS and partner organisations. Inmy own practice and across the countryI have seen that, where change is ledby clinicians and based on evidenceof improved quality of care, staff whowork in the NHS are energised by it andpatients and the public more likely tosupport it.We will empower frontline staff to leadchange that improves quality of care forpatients. Chapter 5 sets out how we willdo this by:• Placing a new emphasis onenabling NHS staff to lead andmanage the organisations in whichthey work. We will re-invigoratepractice-based commissioning andgive greater freedoms and supportto high performing GP practices todevelop new services for their patients,working with other primary andcommunity clinicians. We will providemore integrated services for patients,by piloting new integrated careorganisations, bringing together healthand social care professionals from arange of organisations – community
14 Summary letterservices, hospitals, local authorities andothers, depending on local needs.• Implementing wide rangingprogramme to support thedevelopment of vibrant, successfulcommunity health services. WherePCTs and staff choose to set up socialenterprise organisations, transferredstaff can continue to benefit from theNHS Pension Scheme while they workwholly on NHS funded work. We willalso encourage and enable staff to setup social enterprises by introducing a‘staff right to request’ to set up socialenterprises to deliver services.• Enhancing professionalism .There will be investment in newprogrammes of clinical and boardleadership, with clinicians encouragedto be practitioners, partners andleaders in the NHS. We challenge allorganisations that do business as partof, or with, the NHS to give cliniciansmore control over budgets and HRdecisions.• No new national targets are set inthis report.We will value the work of NHS staff.NHS staff make the difference where itmatters most and we have an obligationto patients and the public to enablethem to make best use of their talents.That is why the Review announces inChapter 6:• New pledges to staff . The NHSConstitution makes pledges onwork and wellbeing, learning anddevelopment, and involvement andpartnership. All NHS organisations willhave a statutory duty to have regardto the Constitution.• A clear focus on improving thequality of NHS education andtraining. The system will be reformedin partnership with the professions.• A threefold increase ininvestment in nurse and midwifepreceptorships. These offer protectedtime for newly qualified nurses andmidwives to learn from their moresenior colleagues during their first year.• Doubling investment inapprenticeships. Healthcare supportstaff – clinical and non-clinical –are the backbone of the service.Their learning and developmentwill be supported through moreapprenticeships.• Strengthened arrangements toensure staff have consistent andequitable opportunities to updateand develop their skills. Sixty percent of staff who will deliver NHSservices in 10 years time are alreadyworking in healthcare.We need tomake sure that they are able to keeptheir skills and knowledge up to date.The first NHS ConstitutionYou asked me to consider the case for anNHS Constitution. In Chapter 7, I set outwhy I believe it will be a powerful wayto secure the defining features of theservice for the next generation. I haveheard that whilst changes must be madeto improve quality, the best of the NHS,the values and core principles which
High Quality Care For All – NHS Next Stage Review Final Report15underpin it, must be protected andenshrined. An NHS Constitution will helppatients by setting out, for the first time,the extensive set of legal rights theyalready have in relation to the NHS. Itwill ensure that decision-making is localwhere possible and more accountablethan it is today, providing clarity andtransparency about who takes whatdecisions on our behalf.Finally, Chapter 8 sets out how we willdeliver this ambitious programme.ConclusionIn the 21 st century, there remains acompelling case for a tax-funded,free at the point of need, NationalHealth Service. This Report celebratesits successes, describes where thereis clear room for improvement, looksforward to a bright future, and seeksto secure it for generations to comethrough the first NHS Constitution. Thefocus on prevention, improved qualityand innovation will support the NHSin its drive to ensure the best possiblevalue for money for taxpayers. It is alsoan excellent opportunity to pursue ourduties to promote equality and reducediscrimination under the Equality andHuman Rights Act.Through this process, we have developeda shared diagnosis of where we currentlyare, a unified vision of where we want tobe and a common language frameworkto help us get there. This Review hasbuilt strong foundations for the futureof the service. It outlines the shape ofthe next stage of reform, with the clarityand flexibility to give confidence for thefuture.Leadership will make this changehappen. All of the 2,000 frontline staffthat have led this Review have shownthemselves to be leaders by havingthe courage to step up and make thecase for change. Their task has only justbegun – it is relatively easy to set out avision, much harder to make it a reality.As they strive to make change happen,they can count on my full support.I would like to thank everyone who hasparticipated in this Review. I am gratefulfor the help they have given to me informing and shaping the conclusions ofthis Report.Best wishes,Professor the Lord Darziof Denham KBEHon FREng, FMedSciParliamentary Under Secretary of StatePaul Hamlyn Chair of Surgery,Imperial College LondonHonorary Consultant Surgeon,Imperial College Healthcare NHS Trustand the Royal Marsden HospitalNHS Foundation Trust
1Change – locally-led, patientcentredand clinically drivenA nationwide process – the core of theNHS Next Stage ReviewAn emergency care practitioner fromthe Cornwall Ambulance Serviceresponds to a call in Port Quin, Cornwall
High Quality Care For All – NHS Next Stage Review Final Report171Change – locally-led, patient-centredand clinically drivenA nationwide process – the core of the NHS Next Stage Review1. The challenge for this Review, setout in my terms of reference, wasto “help local patients, staff and thepublic in making the changes theyneed and want for their local NHS.” 7This approach was necessary becausechange is best when it is determinedlocally. Changing well-loved servicescan be unsettling for patients, publicand staff. Therefore, it is importantthat the local NHS goes through aproper process to determine what willwork best, involving patients, carers,the general public and staff, whilstcommunicating clearly throughout.2. This has meant a very different typeof Review, one driven by the NHSitself. Over the past few months,each region of the NHS has publishedits vision for improving health andhealthcare services.3. These visions are the product of thework more than 2,000 cliniciansand other staff in health and socialcare, who have shown tremendousleadership in creating, shaping andforming the conclusions. In eachregion, they have met in eight ormore groups reflecting different‘pathways of care’ – from maternityand newborn care through to end of7 The terms of reference are available atwww.ournhs.nhs.uklife care. 8 These groups haveconsidered the best available clinicalevidence, worked in partnershipwith thousands of patients, listenedto the needs and aspirations of thepublic and set out comprehensive andcoherent visions for the future.4. The visions are the centrepiece ofthis Review – they report muchprogress, but also identify where,based on clinical evidence, furtherchange is required in order to providehigh quality care. They show howthe NHS is responding to people’sneeds throughout their lives, frombefore birth, through childhood andadolescence and into adulthood andold age. They describe the prioritiesfor action and explain what differencethese priorities, once implemented,will make for local populations.5. The proposals will allow NHS serviceseverywhere to reflect the needs oftheir local communities. People andcommunities across England havedifferent characteristics and differentneeds. Yet too often, the servicesthey receive are not sufficientlyshaped around those characteristicsand needs. If the NHS is to live up8 Some of the strategic health authorities chose tocreate more than eight groups. South West SHAfor instance had a group looking at the best carefor people with learning disabilities
18 1: Change – locally-led, patient-centred and clinically driven1to its founding principles, it mustconstantly respond to those it serves,changing to continue to live up tothe ambition of high quality care.The NHS should be universal, butthat does not mean that it should beuniform. Clear minimum standardsand entitlements will exist, but not aone size fits all model.6. These visions are the start ofresponding to local needs. Theydescribe an NHS that will work withpartner organisations locally to reachout and help people stay healthy,and, when people do need care,provide convenient, high qualitycare. Services will be found in thecommunity, with family doctors,pharmacies and local partnershipstaking a leading role in helpingpeople to stay healthy. In future, theNHS will not be confined to hospitals,health centres or GP surgeries but willbe available online and in people’shomes, whilst the most specialistcare will be concentrated to allowexcellence to flourish.7. Although the specific steps in eachregion’s vision varied as the clinicalworking groups found the bestsolutions for their local populations,their reports include some importantcommon messages:• The staying healthy groupsidentified the need to supportpeople to take responsibility fortheir own health, through reachingout to disadvantaged groups. Theyalso highlighted the expansionof comprehensive screening andimmunisation programmes.• The maternity and newborngroups were clear that womenwant high quality, personal carewith greater choice over placeof birth, and care provided by anamed midwife.• For the children’s pathway, it wasfelt that services need to be moreeffectively designed around theneeds of children and families,delivered not just in health settingsbut also in schools and children’scentres.• The acute care groups gavecompelling arguments for savinglives by creating specialised centresfor major trauma, heart attack andstroke care, supported by skilledambulance services.• Those looking at planned carefound more care could, andshould, be provided closer topeople’s homes, with greater useof technology, and outpatient carenot always meaning a tripto hospital.• For mental health, the groupsrecognised the importanceof extending services in thecommunity, and the benefits togeneral wellbeing and to physicalfrom stronger mental healthpromotion.
High Quality Care For All – NHS Next Stage Review Final Report19• The long-term conditionsgroups explained the need fortrue partnerships between peoplewith long-term conditions andthe professionals and volunteersthat care for them, underpinnedby care plans and better patientinformation.• The necessity for greater dignityand respect at the end of life wasmovingly described by the end oflife groups, as well as the desireto have round the clock access topalliative services.8. It is impossible to do justice here tothe breadth of ambition within thelocal visions – they demand to beread. 9 However, we can illustrateimportant themes with specificlocal promises.Preventing ill health9. There is a clear consensus acrossthe service that the NHS must helppeople to lead independent andfulfilling lives by supporting them tostay healthy. The local NHS wantsto work with others to help peoplestop smoking, to address obesity inchildren and adults, and to tackleexcessive alcohol consumption. Inthe East of England, for example,patients, the public and staff have setthemselves the ambition of reducingthe number of smokers in their regionby 140,000, from its current level ofa million. 109 The local visions are available atwww.ournhs.nhs.uk10 NHS East of England, Towards the best, together,May 2008.They are developing plans for a socialmarketing campaign to encouragepeople to take responsibility for theirown health throughout their lives,whilst reaching out to the mostdisadvantaged in society to helpthem to stay healthy.Ensuring timely access10.There was a strong message thatpeople can still find it difficult toaccess services. Improving access isa priority articulated in every vision,across every pathway of care. Eachregion will continue to improve thequality of access by reducing waitingtimes for treatment, whilst ensuringthat services are available regardlessof where a patient lives. The plansto improve dementia services in theWest Midlands, and South Central’sgoal to deliver round the clockpalliative care for children, are justtwo of the many examples where thelocal NHS will transform access toservices for patients. 11Providing convenient care closerto home11.The local visions will make care closerto home a reality for many patients.For instance, in London, there areplans to deliver more outpatientappointments in communitysettings and carry out routine andstraightforward procedures in GPpractices, where appropriate. 1211 NHS West Midlands, Delivering Our Clinical Visionfor a World Class Health Service, June 2008 andNHS South Central, Towards a Healthier Future,June 2008.12 NHS London, Healthcare for London: A Frameworkfor Action, July 2007.
20 1: Change – locally-led, patient-centred and clinically driven1NHS North West is makingspecialist knowledge more locallyavailable through the use of cardiactelemedicine in GP practices. 13 Thisallows GPs to make a diagnosis, withthe help of specialists at the end of aphone, in their own surgeries.Improved diagnostics12.All the visions emphasised theimportance of rapid access todiagnostics in convenient locations. 14On the one hand, this means testssuch as x-rays and blood testscarried out in primary care or even atpatients’ homes, avoiding needlesstravel to and from hospital and withresults made available more quickly.On the other, it means provisionof interventional radiology andspecialist pathology in centres ofexcellence. To make this a reality, itwill be important to take into accountLord Carter’s review of pathologyservices 15 and draw on the expertiseof professional bodies.Giving more control to patients13.The NHS locally is seeking toforge a new partnership betweenprofessionals, patients and theircarers. NHS North East, for example,is searching for new ways to integratecare around the needs of patients,including community services. 16There will be more use of assistivetechnology and remote monitoringto help patients lead independentlives. It is suggested that patientsshould have more direct control overNHS spending – for instance, NHSYorkshire and the Humber has calledfor the consideration of personalbudgets for people with complexlong-term conditions. 17Ensuring care is effective and safe14.The visions have sent a powerfulmessage that the most effectivetreatments should be available forall NHS patients. Their plans fortransforming treatment for heartattack, stroke and major traumavividly illustrate this. For stroke – thethird largest cause of death andsingle largest cause of disability inthe UK – the clinical evidence clearlydemonstrates that the quality of careis greatly improved if stroke is treatedin specialist centres. 18 Each region istherefore pushing forward with thedevelopment of specialised centresfor their populations with access to24/7 brain imaging and thrombolysisdelivered by expert teams. Forexample, by 2010, NHS South EastCoast intends that all strokes, heartattacks and major injuries will betreated in such specialist centres. 19Once implemented, these planswill save lives. From every corner ofthe NHS, there was also a strongemphasis on the importance ofpatient safety. They all aim to makehospitals and health centres cleanand as free of infection as possible.13 NHS North West, Healthier Horizons, May 2008.14 See for instance, NHS West Midlands, DeliveringOur Clinical Vision for a World Class HealthService, June 2008.15 Lord Carter, Report of the Review of NHSPathology Services in England, 2006.16 NHS North East, Our vision, our future, June 2008.17 NHS Yorkshire and the Humber, HealthierAmbitions, May 2008.18 A. Buchan, Best practice in Stroke Care 2007,presentation at the Healthcare for Londonconference, 19 February 2007.19 NHS South East Coast, Healthier People, ExcellentCare, June 2008.
High Quality Care For All – NHS Next Stage Review Final Report2115.The visions also emphasise theimportance of geographical factors inthe effectiveness and safety of care.This was reinforced by a submissionreport to this Review by theCommission for Rural Communities. 20High quality care16.From the vision documents, andfrom my own visits to every regionof the country, the message thatimproving quality of care is whatexcites and energises NHS staff hasbeen loud and clear. Internationalevidence shows that we have madegreat improvements but that there isfurther to go. Nolte and McKee havefound that the NHS made a 21 percent reduction in premature mortalityrates from 1997–98 to 2002–03,compared to a 4 per cent reductionby the US. 21 However, there is muchmore to do, as our starting pointwas worse than our internationalcomparators.17.Every region of the NHS hasarticulated its aspiration for highquality care for their populations.NHS South West, for example, hasset a goal of matching the longestlife expectancy in Europe. 22 Usingclinical expertise, NHS East Midlandswill publish standard quality measuresallowing patients to compare theperformance of different providers. 2320 Commission for Rural Communities, Tackling ruraldisadvantages, May 200821 E. Nolte and N. McKee, “Measuring the Healthof Nations, updating an earlier analysis, 2008,”Health Affairs 27:10, 58–71.22 NHS South West, Improving Health, May 2008.23 NHS East Midlands, From Evidence to Excellence,June 2008.Personal care18.All the visions emphasised the need toorganise care around the individual,meeting their needs not just clinically,but also in terms of dignity andrespect. NHS South West, for instance,recognised that the best diabetesservices are tailored to individuals,comprising a mix of structurededucation, lifestyle advice andappropriate screening. 24 Personal carealso considers the needs of the patientwithin the context of their supportnetwork, including carers, family andemployers.Innovation19.The desire to bring the benefits ofinnovation to patients more rapidly isa common theme. Across the country,from the South West to the NorthEast, we heard that there is muchto be gained by the NHS working inpartnership with higher educationinstitutions and the private sector.And there is very strong supportfor greater collaboration betweenprimary, secondary and social care.20.These are the changes patients andpublic can expect to see. However,there was one more common theme– all the local visions made the casefor national action to enable localchange. This report therefore sets outhow we will help the local NHS toensure that the pace of change doesnot slow and that the expectationsof patients and the public are met.It describes how we will respond tothe challenges the visions set, helpingpatients, the public and frontline staffto achieve their collective ambitions.24 NHS South West, Improving Health, May 2008.
22 1: Change – locally-led, patient-centred and clinically driven121.This report addresses big nationalthemes such as improving quality,leadership and the workforce. 25It focuses on what must bedone centrally to support localorganisations. It illustrates that therole of the Department of Health isto enable the visions created by thelocal NHS to become a reality, whilstensuring that universality, minimumstandards and entitlements areretained and strengthened. It setsout how we will back local leaders todeliver for their communities.25 National Groups were established as part of theReview in October 2007 on Quality and Safety,Leadership, Primary and Community Care,Workforce, and Innovation.
High Quality Care For All – NHS Next Stage Review Final Report23
2Changes in healthcareand societyThe challenges facing the NHS in the 21 st centuryA patient undergoes plasma exchangeat the Royal Liverpool Hospital
High Quality Care For All – NHS Next Stage Review Final Report252Changes in healthcare and societyThe challenges facing the NHS in the 21 st century1. Every SHA vision identified thechallenges faced in their region ofthe country. 26 Drawing togetherthe common themes, it is possibleto take a national perspective. Thedrivers for change in healthcare andsociety are beyond the control ofany single organisation. Nor can theybe dealt with simply or reactively atnational level. This reinforces the casefor enabling and encouraging theNHS locally to anticipate and respondproactively to the challenges ofthe future.2. In its earliest years, the NHS facedsignificant challenges to providebasic care when people fell sick andto tackle communicable diseases.Nowadays, diseases such as measles,polio and diphtheria, previouslycommon and deadly to the post-wargeneration, are rare and preventable,thanks to vaccination programmes,and treatable, thanks to advances inresearch and technology.3. Nationally, the NHS in the 21 stcentury faces different challenges,which I would summarise as: risingexpectations; demand driven bydemographics; the continuingdevelopment of our ‘informationsociety’; advances in treatments;26 See for instance Healthcare for London the Casefor Change.the changing nature of disease; andchanging expectations of the healthworkplace.4. These six challenges are not limitedto England – they are commonto all advanced health systems,most of which are considering orundertaking significant reforms inresponse. 27 Not all the challenges areunique to healthcare – their impactis being felt across public services.The Government is committed totransforming adult social care, forexample, so that people have morechoice and control over integrated,high quality services. 28 In addressingthese challenges for the NHS we havethe opportunity to set a direction forwider public service reform.Challenge 1: Ever higherexpectations5. Wealth and technology havechanged the nature of our society’soutlook and expectations. The 1942Beveridge Report 29 identified the ‘FiveGiants’ – want, disease, ignorance,squalor and idleness – that a civilised27 For an influential examination of the need toreform the US health system see Porter andTeisberg, Redefining Health Care, 2006.28 Putting People First, A shared vision andcommitment to the transformation of adult socialcare, HM Government, December 2007.29 Report of the Inter-Departmental Committeeon Social Insurance and Allied Services, CrownCopyright (1942).
26 2: Changes in healthcare and society2society needed collectively to address.In 1946, the Labour governmentlegislated for the creation of aNational Health Service, and throughthe leadership of Nye Bevan theNHS was born on 5 July 1948. Asan information leaflet from the timeexplained, its purpose was simple: to“relieve your money worries in timeof illness.” 306. We tend to use health services atparticular stages of our lives, sohealth professionals are especiallyexposed to each generation’sdemands and expectations. We cananticipate these changing demands,and in so doing equip the healthservice to deal with the future.7. For those in later life, healthpractitioners will see a generationwith expectations of more tailoredtreatment received at a time andplace convenient to them. As peoplecontinue to live longer, they willcontinue to access services for longer,and are likely to live more of theirlife with one or more long-termcondition. 31 They will make demandsthat are not just larger but different.They still expect the clinician tolead, but expect a bigger role forthemselves in decision-making duringtheir care.30 The New National Health Service, Central Officeof Information for the Ministry of Health, CrownCopyright (1948).31 See Wanless, Securing our Future Health (2002)for an explanation on how the NHS must notsimply help people live longer, but must alsoensure that those extra years are active, highquality ones.8. We are also beginning to see theimpact, and opportunities, that faceus from recent generations – thechildren of the last three decades ofthe 20 th century. These generationsare influenced by new technologiesthat provide unprecedented levelsof control, personalisation andconnection. They expect not justservices that are there when theyneed them, and treat them how theywant them to, but that they caninfluence and shape for themselves.Better still, they will want servicesthat ‘instinctively’ respond to themusing the sophisticated marketingtechniques used by other sectors. 32This is more than just a challenge forhealthcare, but for our whole modelof how we think about health.Challenge 2: Demand driven bydemographics9. The fact that people are living longerthan ever is a cause for celebration.The NHS can be justly proud of thepart it has played in our ever-growinglife expectancy. Yet our ageingpopulation also poses a challengeto the sustainability of the NHS.By 2031, the number of over 75year-olds in the British populationwill increase from 4.7 million to8.2 million. 33 This older age groupuses a disproportionate amount ofNHS resources; the average over-85year old is 14 times more likely tobe admitted to hospital for medicalreasons than the average 15-3932 For instance the personal recommendations givenby Amazon and other internet retailers.33 Office of National Statistics, PopulationProjections, 23 October 2007.
High Quality Care For All – NHS Next Stage Review Final Report27year old. 34 Whilst just 17 per centof the under 40s have a long-termcondition, 60 per cent of the 65 andover age group suffer from one ormore. 3510. If the NHS remains a primarilyreactive service, simply admittingpeople into hospital when they areill, it will be unable to cope with theincreased demands of an ageingpopulation. Our longer life spansrequire the NHS to be forwardlooking,proactively identifying andmitigating health risks.Challenge 3: Health in an age ofinformation and connectivity11. Across society, the internet hastransformed our relationship withinformation. High-speed web access isfound in millions of homes. By 2012,74 per cent of UK homes are expectedto have broadband internet access,transforming how people will seek anduse information in their lives. 3612. The implications for health andhealthcare are profound. It is easierto access information on how tostay healthy than ever before. Peopleare able to quickly and convenientlyfind information about treatmentand diseases in a way that waspreviously impossible. They are able,and want, to engage with othersonline, sharing information andexperiences. They want to do theirown research, reflect on what theirclinicians have told them and discuss34 Hospital Episode Statistics Data 2005/06.35 Department of Health, Raising the Profile ofLong-term Conditions: A Compendium ofInformation, January 2008.36 UK Broadband Overview, January 2008, http://point-topic.com/content/operatorSource/profiles2/uk-broadband-overview.htmissues from an informed position. Thechallenge is ensuring that people areable to access reliable information.Evidence shows that clinicians havesometimes been slower in exploitingthe potential of new informationsources, such as the internet, thanothers. 37 If that trend continues, thereis a danger that people will have tonavigate through myth and hearsay,rather than get easy access toevidence-based medical knowledge.Challenge 4: The changing natureof disease13. The NHS in the 21 st centuryincreasingly faces a disease burdendetermined by the choices peoplemake: to smoke, drink excessively, eatpoorly, and not take enough exercise.Today, countless years of healthy lifeare lost as the result of these knownbehavioural or lifestyle factors.14. Wealth and technology have givenus many choices, including onesthat are damaging to our health andwellbeing. We drive to work andschool instead of walking or cycling;we eat high fat, high salt dietswhen fresh fruit and vegetables areavailable in unprecedented volumes;and we consume more alcohol thanis good for us. 3837 Kaimal AJ et al. “Google Obstetrics: who iseducating our patients?” American Journalof Obstetrics and Gynecology, June 2008,198(6):682.e1-5.38 In the ten years to 2003, the number of walkingtrips fell by 20% (National Statistics 2004). Theaverage number of cycling journeys fell from 20person per year in 1992/1994 to 16 in 2002/2003(DfT). 1 in 4 adults (10 million) regularly exceedthe recommended daily limits of 2-3 units(women) and 3-4 units (men) (ONS GeneralHousehold Survey 2006).
28 2: Changes in healthcare and society215. We know that the choices peoplemake when faced with this increasingrange of possibilities are stronglyinfluenced by their circumstances.Stress, income, employmentprospects and environmental factorsconstrain the healthy choices opento people, and can make shorttermchoices more attractive despiteadverse health consequences in thelonger term. The health service isnot always good enough at helpingpeople make the right choices – 54per cent of patients said that theirGP had not provided advice on dietand exercise, whilst 72 per cent saidthat their GP had not asked aboutemotional issues affecting theirhealth during the last two years. Welag behind our peers internationally. 3916. Unhealthy choices and missedprevention opportunities are inpart the cause of the growth in theprevalence of conditions such asdiabetes, depression, and chronicobstructive pulmonary disease. TheWHO estimates that depression, forinstance, will be second only to HIV/AIDS as a contributor to the globalburden of disease by 2030, up fromfourth place today. 40 These diseasescannot always be cured, but theycan be managed, and the symptomsameliorated.39 2006 Commonwealth Fund international HealthPolicy Survey of Primary Care Physicians.40 This is based on the impact of depression ofDisability Adjusted Life Years (DALYs). C. Mathersand D. Loncar, Projections of Global Mortality andBurden from Disease 2002 to 2030, PLoS Med3(11): e442.17. The NHS and all of its many partnersmust respond to this shifting diseaseburden and provide personalisedcare for long-term conditions, a goalalready set out in the Government’sOur health, our care, our say WhitePaper. 41 We need to make this goala reality. Providing personalised careshould also help us to reduce healthinequalities, as the households withthe lowest incomes are most likely tocontain a member with a long-termcondition. 42Challenge 5: Advances in treatments18. The past 60 years have seen bigdevelopments in our capacity tounderstand the nature and impactof existing disease, from imagingto pathology. We are improvingour understanding of how diseasein one organ increases the riskof damage to others. With theadvances currently underway ingenomic testing, we may be able topredict future disease rather thansimply understand present illness. 43Advances in neurosciences are tellingus more about the importance ofpregnancy and early childhood forsubsequent health and wellbeing. 44Our understanding of the widerdeterminants of physical and41 Our health, our care, our say, HM Government,January 2006.42 Department of Health, Raising the Profile oflong-term Conditions: A Compendium ofInformation, January 2008.43 K Philips et al, “Genetic testing andpharmacogenomics: issues for determining theimpact to healthcare delivery and costs,” Am J ofManaged Care, 2004 Jul; 10(7): 425-432.44 Center on the Developing Child at HarvardUniversity (2007) A Science-based framework forearly childhood policy: using evidence to improveoutcomes in learning, behaviour and health forvulnerable children Cambridge, MA.
High Quality Care For All – NHS Next Stage Review Final Report29mental health and their impact andinteractions is improving all the time.All of this presents the NHS withan unprecedented opportunity tomove from reactive diagnosis andtreatment to be able to proactivelypredict and prevent ill health.19. Improved technology is enablingpatients that would once have beenhospitalised to live fulfilling lives inthe community, supported by theirfamily doctor and multi-professionalcommunity teams. Where patientswere once confined to hospital,Wireless and Bluetooth technologiesallow their health to be monitoredin their own homes. For instance,a thousand people in Cornwallare having simple-to-use biometricequipment installed in their ownhomes, enabling them to monitortheir own blood pressure, bloodsugar and blood oxygen levels. 45This information helps to preventunnecessary hospital admissions.This is better for patients and theircarers, delivers improved outcomes,and is a very efficient way of usingNHS resources. An even bigger factorin the shift from hospital to home isthe up-skilling of a wider range ofstaff, and the removal of barriers tomore independent working in thepatient’s interest.20.We continue to develop pioneeringtreatments for diseases. For the sameillness, open surgery leaves patientsin hospital for several weeks wherekeyhole surgery enables them togo home in just a few days. With45 Cornwall is one of the Whole SystemDemonstrator sites promised on page 120 of theOur health, our care, our say White Paper.advances in robotics, patients canlook forward to scar-free surgery. 46A major expansion in our abilityto offer psychological therapiesfor depression and anxiety willmean that many people who werepreviously untreated will in futurereceive treatment based on the bestinternational evidence.21. Healthcare itself is on a journeywhere the emphasis of care is shiftingto extending wellness and improvinghealth. This is making healthcaremore complex, with a broader rangeof interventions possible. In someareas of practice, such as for acutecoronary syndrome, this has led toincreased standardisation wherethe evidence shows that followingprotocols leads to better outcomes. 47In others, such as the treatmentof paediatric cancers, innovationsmean that best practice is constantlychanging and evolving. 48 For patients,these medical advances often meanlonger and more fulfilling lives. Thereare, however, broader implications.Greater clinical uncertainty requiresboth greater professional judgementas to what is the right course ofaction for an individual patient anda more open and honest discussionof risks to enable patients to makeinformed decisions.46 For more information see Darzi, Saws and Scalpelsto Lasers and Robots – Advances in Surgery (2007).47 SA Spinler, “Managing acute coronary syndrome:evidence-based approaches,” Am J Health SystPharm, 2007 Jun 1;64(11 Suppl 7):S14-24.48 P. Paolucci, “Challenges in prescribing drugsfor children with cancer,” Lancet Oncol., 2008Feb;9(2):176-83.
30 2: Changes in healthcare and society2Challenge 6: A changing healthworkplace22. In recent years, Britain has becomea ‘knowledge economy’ withthe majority of new jobs beingin knowledge-based industries. 49Healthcare has always been aknowledge-led sector, relyingon expert learning and depth ofexperience. Increasing complexityis an integral feature of modernhealthcare. With new advances inclinical science and new treatmentsfor patients, come fresh challengesfor professionals. Whether in acuteor community settings, easy andconvenient access to knowledge isan essential part of a modern andeffective workplace.23. Expectations of work in healthcareare changing, with people todayseeking quality work. 50 Healthcareprofessionals expect the depth oftheir expertise to be recognisedand rewarded, and their skills tobe developed and enhanced. Theyseek personal fulfilment as well asfinancial reward. 51 They understandthe demands of accountability andwelcome transparency as a routeto achieving true meritocracy. Staffexpect a better work/life balance andmore respect and regard for pressureson their time beyond those of theirprofession.49 Ian Brinkley, The Knowledge Economy: HowKnowledge is Reshaping the Economic Life ofNations, March 2008, The Work Foundation.50 For more on the importance of work quality seeG. Lowe, The Quality of Work: A People-CentredAgenda, 2000.51 On doctor’s motivation see S. Dewar etal., Understanding Doctors: HarnessingProfessionalism, King’s Fund, May 2008.24. High quality work is not simply amatter of a good deal for staff andfor patients. It is also essential tomeeting the productivity challenge:high quality workplaces make bestuse of the talents of their people,ensuring that their skills are upto date, and their efforts neverwasted. The public rightly expecttheir taxes to be put to best use.For those working in the NHS thereis a need to reduce unnecessarybureaucracy, freeing up their time tocare for patients, within the resourcesavailable. Creating high qualityworkplaces requires great leadershipand good management.Where we stand today25. I believe we are well placed torespond to these challenges not onlybecause of the progress made overrecent years but also because of thefundamental basis of our NHS as atax-funded system, based on clinicalneed rather than ability to pay. Inthis respect, the NHS is unlike healthsystems in comparable countries, andis particularly well positionedto respond.26. For insurance companies, there is noincentive to invest in the preventionof ill health as patients may moveto a different scheme. Diagnosticsincrease the capacity of the NHS toreach out to predict and prevent illhealth, but in other systems theyincrease their capacity to excludethose at risk from the protectionthey need.
High Quality Care For All – NHS Next Stage Review Final Report3127. The Wanless Report of 2002 madethe case for additional investment inthe NHS, to which the Governmenthas responded. 52 The NHS is nowfunded at close to the EU average. 53In 2009/10, the NHS budget willexceed £100 billion. The NHS hasthe financial resources it needs.their chances of poor health anddependency on the NHS. The answerto the challenges the NHS faces istherefore to focus on improving thequality of care it provides.28. However, the NHS must usethese resources well. Increasingexpectations, an ageing population,a rise in lifestyle disease and the costof new treatments will all imposegreater costs.29. The NHS must respond by improvingthe quality of care it provides. Thisis because the evidence shows that,in general, higher quality care worksout better for patients and thetaxpayer. For instance, day surgeryfor cataracts delivers the highestquality of care with no admission tohospital. 54 High quality care is safe,meaning no avoidable healthcareassociated infections. This is obviouslybetter for patients and also reducesthe need for costly post-infectionrecovery in hospital. Finally, highquality care involves giving thepatient more control over theircare, including information to makehealthy choices, which will reduce52 Wanless, Securing our Future Health (2002).53 In 2008 the UK is expected to spend 9.0% ofits GDP on health, compared with an averageof 9.5% amongst the 15 pre-enlargementEU members.54 Cataract extraction was one of a “basket” of25 procedures recommended by the AuditCommission in 2001 as suitable for day surgery.Day surgery for cataract removal is less thantwo thirds of the cost of doing it as an inpatientprocedure (RCI 2005).
3High quality care forpatients and the publicAn NHS that works in partnership to prevent ill health,providing care that is personal, effective and safeA session at the Tower HamletsExercise and Nutrition Programme,Mile End Hospital, London
High Quality Care For All – NHS Next Stage Review Final Report333High quality care for patients and the publicAn NHS that works in partnership to prevent ill health, providing carethat is personal, effective and safeIntroduction1. This Review is about achieving thehighest quality of care for patientsand the public. I have heard frompatients and staff, and I know frommy own experience, that when in thecare of the NHS, it is the quality ofthat care that really matters. Peoplewant to know they will receiveeffective treatment. They wantcare that is personal to them, andto be shown compassion, dignityand respect by those caring forthem. People want to be reassuredthat they will be safe in the care ofthe NHS. And whilst most peoplerecognise their health is theirresponsibility, they also look tothe NHS for help.2. The investment and reform of thepast decade have given us theopportunity to pursue this ambitiousagenda for patients and the public.3. Ten years ago, today’s qualityreform agenda would have seemedparticularly challenging. The extracapacity in the NHS today gives allof us the opportunity to focus onimproving quality. To achieve that weneed to:• Help people to stay healthy .The NHS needs to work with itsnational and local partners moreeffectively, making a strongercontribution to promoting health,and ensuring easier access toprevention services.• Empower patients . The NHSneeds to give patients more rightsand control over their own healthand care, for more personal care.• Provide the most effectivetreatments. Patients needimproved access to the treatmentsthey need supported by improveddiagnostics to detect diseaseearlier.• Keep patients as safe aspossible. The NHS must striveto be the safest health system,keeping patients in environmentsthat are clean, and reducingavoidable harm.Helping people to stay healthy4. Our health starts with what we dofor ourselves and our families, but theenvironment we live in influences ourdecisions and ultimately our health.Some people live in circumstancesthat make it harder to choose healthylifestyles. Changing this environmentcan influence the way people lookafter their own and their families’health. This is particularly important ifwe are to tackle inequalities in healthstatus and outcomes.
34 3: High quality care for patients and the public35. Patients and the public want theNHS to play its part in helping themto stay healthy. Nearly a quarter ofpeople felt health was ‘mainly my’responsibility, and a further 60 percent felt it was ‘mainly me withsupport from the NHS.’ 55 Alongsidethe NHS, we need to ensure that arange of organisations – public andprivate – play their part in supportingpeople to stay healthy.6. Locally, the NHS and local authoritiesare working closely together toimprove health and wellbeing,prompted by their legal duty toco-operate in improving outcomesfor their populations. The dutyis based on a formal assessmentof people’s needs (Joint StrategicNeeds Assessments) developedbetween primary care trusts, localauthorities and other local partners,including police authorities andlocal hospitals, to tackle the mostimportant factors in improvinghealth. These plans focus not onlyon tackling clear health prioritiessuch as smoking, childhood obesityand teenage pregnancy, but also onbroader factors such as poor housing,education, local transport andrecreational facilities.Focusing on helping prevent ill health7. As well as improving partnershipworking, the NHS itself hasstrengthened its contributionto preventing ill health throughsustained investment over the past55 Primary and Community Care Deliberative Event,run by HCHV, April 2008.decade. As the visions show, thefoundations of good health andhealthy lifestyles are laid down in thevery earliest stages of life. The Childand Young People’s Health Strategydue in the autumn will seek to buildon the new Child Health PromotionProgramme that sees highly skilledhealth visitors and school nursessupporting families on health andparenting from pregnancy onwards.It will also bring with it a furtherfocus on improving services foradolescents. 568. Progress has been made in detectingillnesses earlier and preventing themfrom worsening, including in cardiacand cancer services. Much of thisprogress has been achieved throughnational screening and immunisationprogrammes. We need to continuethis progress.9. We will therefore strive to accept andimplement every recommendationfor screening and vaccinationprogrammes that the relevantnational expert committees make. 57This will be a pledge within theNHS Constitution so that peopleknow these services will be availablewithout question, where they areclinically and cost effective.56 The Children’s Plan, published in December2007 by the Department for Children, Familiesand Schools (DCFS) committed to DCFS and theDepartment of Health publishing a joint childhealth strategy.57 These are the Joint Committee on Vaccination andImmunisation (JCVI) and the National ScreeningCommittee (NSC).
High Quality Care For All – NHS Next Stage Review Final Report3510. There remains significant room forimprovement, especially across therisk factors identified in chaptertwo – disease, smoking, excessivedrinking, poor diet and lack ofexercise. The NHS must now focuson preventing ill health for individualsand giving them the opportunitiesand support to improve their health.11. Vascular conditions are majorcauses of early death, long-termillness and health inequality. Theseinclude coronary heart disease,stroke, diabetes and kidney disease.Taken together, they affect over4.5 million people in England, andare responsible for over 170,000deaths every year. 58 Some of thesedeaths could be prevented if peopleunderstood their own health status.Where people can act to decreasetheir chance of developing particularforms of ill health, we want peopleto understand clearly what therisks are to their health and whatthey can do to prevent the onset ofirreversible disease.12. Earlier this year we announced helpfor people to do this through vascularhealth checks for everyone aged40-74. 59 These will be introducedfrom 2009, and rolled out throughGPs, pharmacies and communityclinics. By 2012, we expect threemillion people every year to beoffered a check, preventing at least58 See Department of Health, Putting PreventionFirst, April 2008.59 For more information on the rationale for theage range of 40-74 see Department of Health,Technical consultation on economic modelling ofa policy of vascular checks, June 20089,500 heart attacks and strokesand 4,000 people from developingdiabetes each year. We will makeit easy and convenient to accessthese checks in a variety of places. Inparticular, we believe that pharmacieshave a key role to play as providers ofprevention services. 6013. We need to raise awareness of thisnew service. We will do this througha nationwide ‘Reduce Your Risk’campaign, which will be launchedduring 2009 alongside vascularhealth checks. This campaign willclearly explain what people can doto reduce their risks: stop smoking,maintain a healthy weight, increasephysical activity, lower bloodpressure. We will also work with thirdsector groups to reach those lesslikely to access services.Ensuring that people have convenientaccess to prevention services14. Working with their local partners,every primary care trust willcommission comprehensive wellbeingand prevention services, with theservices offered customised to meetthe specific needs of their localpopulations. This reflects the findingof the SHA staying healthy groups,who called for prevention serviceson “an industrial scale.” Our effortsmust be focused on six key goals:tackling obesity, reducing alcoholharm, treating drug addiction,reducing smoking rates, improving60 Department of Health, Pharmacy in England:building on strengths – delivering the future,April 2008.
36 3: High quality care for patients and the public3sexual health and improving mentalhealth. Examples of services thatwe expect local PCTs to developand expand include alcohol briefinterventions, exercise referral,weight management and talkingtherapies, and we expect the reach ofthese services to increase as the NHSseeks to support all of us in makinghealthier choices.15. Reflecting this new priority forthe NHS, and the need to worktogether with partners from allsectors of society, we will launchshortly a Coalition for Better Health.The Coalition will be a new set ofvoluntary agreements betweengovernment, private and third sectororganisations, focused on the actioneach needs to take to achieve betterhealth outcomes for the nation. Aswe announced in Healthy Weight,Healthy Lives earlier this year, its initialpriority will be combatting obesityby supporting healthier food, morephysical activity, and encouragingemployers to invest more in thehealth of their employees. 6116. All too often, those living in povertyare poorest in health. 62 As set outin the recent Health Inequalitiesstrategy, the root causes of illhealth lie heavily in people’s lifecircumstances. 63 Excellent preventionservices are a matter of fairness, and61 Healthy Weight, Healthy Lives, HM Government,May 2008.62 See for instance M. Marmot, “The SocialDeterminants of Health Inequalities,” Lancet 2005,365, 1099-1104.63 Department of Health, Health Inequalities:Progress and Next Steps, June 2008.primary and community serviceshave a pivotal role to play in reachingout to those communities wheresocio-economic factors are linked toreduced life expectancy and higherprevalence of illness.17. In my Interim Report, I set out plansto tackle inequalities in primarycare by establishing over 100 newGP practices in the areas of thecountry with the fewest primary careclinicians and the greatest healthneeds – more often than not, theseare our most deprived communities.18. To improve access to primary careservices, my interim report alsoannounced that we would investadditional resources to enable thelocal NHS to develop over 150 GP-ledhealth centres to supplement existingservices. The services provided inthese centres will reflect local needsand priorities. Primary care trusts willensure that these centres are open atmore convenient hours that fit withpeople’s lifestyles (8am to 8pm everyday) and that they are open to anymember of the public, so that peoplecan walk in regardless of whichlocal GP service they are registeredwith. People will be offered theopportunity to register at these newfacilities, should they choose.19. These health centres will provideadditional, convenient access toprimary care services, including inthe evenings and at weekends. PCTshave been developing proposalslocally not only for additional accessto GP services, but also to a much
High Quality Care For All – NHS Next Stage Review Final Report37broader range of services such asdiagnostic, mental health, sexualhealth, social care and healthy livingservices to match the needs of theircommunities. This broader range ofservices will not inhibit any patient’scontinuity of care. It is preciselybecause these needs vary that thereis no national blueprint.20. NHS Next Stage Review: Our Visionfor Primary and Community Carewill be published shortly. Themain features of that strategy aresummarised in this report. NHSprimary and community care servicesare strongly rooted in their localcommunities and patients, carersand their families rightly value thepersonal relationships and continuityof care that they provide. Thestrategy will describe a vision forprimary and community care thatbuilds on these strengths and raisesour ambitions. It will focus on makingservices personal and responsiveto all, promoting healthy lives andstriving to improve the quality ofcare provided.21. Currently the incentives for GeneralPractice focus largely on the effectivemanagement of long-term conditionsrather than seeking to preventthose conditions in the first place.We will change this by supportingfamily doctors to play a wider role inhelping individuals and their familiesto stay healthy. We will work withprofessional and patient groups toimprove the world-leading Qualityand Outcomes Framework to providebetter incentives for maintaininggood health as well as good care.Family doctors, practice nursesand other primary and communityclinicians will have greateropportunities and incentives to advisepeople on measures they can take toimprove their health. We will supportthis by investing new resources inthe areas that are worst affected byobesity and alcohol-related ill health.22. For many people, one of themost convenient places to accesspreventive services is at their place ofwork. Evidence shows that employerscan make a very positive contributionto the health of their employees,and that where they invest inemployee health they very often reapbenefits in employee motivation,in productivity and in profit too. 64To encourage this investment, weare working in partnership with theDepartment for Work and Pensionsand Business in the Community toensure that 75 per cent of FTSE 100companies report on their employee’shealth and wellbeing at board levelby 2011.23. Preventing ill health often alsomeans helping people stay inemployment. A recent review ofthe health of the working agepopulation underlined the benefitsof work and employment for our64 Wang PS et al., “The costs and benefits ofenhanced depression care to employers,” ArchGen Psychiatry. 2006 Dec;63(12) found thatboth employees and employers would benefitif employers improved access to mental healthservices for their employees.
38 3: High quality care for patients and the public3overall health and well-being. 65 Ithighlighted the rapidly rising risksto long-term health if people arenot supported sufficiently early toaddress issues that stop them fromworking, with back problems andmental ill health among the mostsignificant. From next year, we willintroduce integrated Fit for Workservices in primary and communitycare, bringing together accessto musculoskeletal services andpsychological therapies for example.This will help people get the supportthey need to return to appropriatework faster.Empowering patients: more rightsand control over health and care24. Over the last decade, the NHShas gradually given patients morecontrol over their own care. Peoplereferred for secondary or hospitalbasedcare can now choose freelywhere they receive their treatment.And increasingly, there is betterinformation available for patientsabout outcomes of care such asthe information at GP-practice levelfrom the Quality and OutcomesFramework.25. Patients empowered in this wayare more likely to take greaterresponsibility for their own health,and to dedicate their own time,effort and energy to solving theirhealth problems. This partnershipis especially important for thosewith long-term conditions and their65 Dame Carol Black, Working for a HealthierTomorrow, Crown Copyright, March 2008.carers. We must therefore continueto empower patients with greaterchoice, better information, and morecontrol and influence.Greater choice26. Today, people who need to bereferred for secondary care have freechoice of any hospital or treatmentcentre – NHS or independent sector –that can provide NHS quality care atthe NHS price. Choice gives patientsthe power they need in the system,as NHS resources follows patientsin the choices they make. Wherepatients find it difficult to expresspreferences, it is the role of staff totake steps to ensure that patientscan benefit from greater choice.Choice in public services is sometimespresented as the pre-occupation ofthe wealthy and the educated, yetthe evidence shows that it is thepoorest and least well educated whomost desire greater choice. 66 Webelieve that choice should becomea defining feature of the service. Ahealth service without freedom ofchoice is not personalised. So theright to choice will now be part ofthe NHS Constitution, ensuring thatpeople become more clearly awareof it.66 The British Social Attitudes survey found that67% of semi-routine and routine workers wantmore choice compared to 59% of managerial andprofessional workers, and 69% of people withno formal educational qualifications want morechoice compared to 55% of those with highereducational qualifications. Appleby & Alvarez,British Social Attitudes Survey 22nd Report, PublicResponses to NHS Reform, 2005.
High Quality Care For All – NHS Next Stage Review Final Report3927. It is because we believe that choicehas given more control to patientsand helped to develop services thatrespond to their expectations, thatwe will now put a stronger focuson extending choice in primaryand community care. In 1948, theGovernment informed members ofthe public that they had a choiceof GP. 67 People can indeed choosewhich GP practice to register with,but in some areas the degree ofchoice is still restricted by closedpatient lists, by practices saying theyare ‘open but full’, or by narrowpractice boundaries. We will supportthe local NHS, working with GPs, togive the public a greater and moreinformed choice, not just for GPservices but for the wider range ofcommunity health services.28. Providing greater choice of GP willmean developing fairer rewards forpractices that provide responsiveservices and attract more patients.At present, most GP practicesreceive historic income guaranteesthat do not necessarily bear relationto the size or needs of the patientpopulation they now serve, or thenumber of patients they see. Wewill work with GP representativesto manage the phase out of theseprotected income payments, so thatmore resources can go into providingfair payments based on the needs ofthe local population served by eachpractice.67 The New National Health Service, Central Officeof Information for the Ministry of Health,CrownCopyright (1948).Better information29. We want patients to make the rightchoices for themselves and theirfamilies. So we will empower themto make informed choices. Thefirst step towards this vision wastaken with the launch of the NHSChoices website, with a variety oflimited quality information (suchas Healthcare Commission ratingsand MRSA rates at an organisationlevel). 68 The next stage is to empowerpatients with clear information onthe quality of each service offered byevery NHS organisation – across allsettings of care.30. In practice, this means easy-tounderstand,service-specific,comparable information availableonline. The information will be onevery aspect of high quality care –on safety such as cleanliness andinfection rates, on experiences suchas satisfaction, dignity and respect,and on measures of outcomes thatinclude patients’ views on the successof treatments. Chapter 4 sets out inmore detail how we will do this. Andthe NHS Constitution will guaranteethat this information on quality willbe freely and openly available as wellas reliable.31. In primary care, we will continue todevelop the NHS Choices websiteto include more comparativeinformation about the range ofservices offered by GP practices,their opening times, the views oflocal patients, and their performance68 NHS Choices can be found at www.nhs.uk
40 3: High quality care for patients and the public3against key quality indicators. Wewill also develop the website so thatit offers a simpler way of registeringelectronically with a GP practice.These national efforts to improvechoice of GP should be mirrored atlocal level, for instance through localNHS information packs for peoplewho have just moved house.32. During the Review, patients have toldus that they need better informationand more help to understand howto access the best care, especiallyurgent care, when they need it. I saidin my interim report that we shouldconsider options to introduce a newthree-digit telephone number to helppeople find the right local service tomeet their urgent, unplanned careneeds. Several of the visions includedplans to develop such a number. 69We will learn from this local work aswe consider nationally the costs andbenefits of an urgent care number.We will set out further detailsfrom this next phase of work laterthis year.Increased control33. We have to keep up with theexpectations of the public. Thiswill mean allowing people toexercise choice and be partners indecisions about their own care,shaping and directing it with highquality information and support.Empowering patients in this wayenables them to use their personalknowledge, time and energy for69 See for instance the NHS East Midlands and NHSLondon visions.solving their own health problems.The fundamental solution to the riseof lifestyle diseases is to change ourlifestyles. While the NHS can supportand encourage change, ultimately,these are decisions that can only bemade by us as individuals. Those withtwo or more long-term conditionsare more likely to be obese, eatless healthily and smoke than thosewith one or none. 70 People needto know the risks and have theopportunity to take control of theirown healthcare. To help with this, theDepartment of Health will publish anew Patients’ Prospectus by the endof this year to provide patients withlong-term conditions the informationthey need about the choices whichshould be available to them locallyand to enable them to self-care inpartnership with health and socialcare professionals.34. Beyond this, international bestpractice suggests that control by apatient is best achieved through theagreement of a personal care plan. InGermany, nearly two-thirds of peoplewith long-term conditions have apersonal care plan, whereas the sameis true for only a fifth of people inthis country. 71 Care planning createspackages of care that are personal tothe patient. It involves working withprofessionals who really understandtheir needs, to agree goals, theservices chosen, and how and whereto access them. Personal care plans70 Department of Health, Long term conditions:Compendium of Information, January 2008.71 2006 Commonwealth Fund International HealthPolicy Survey of Primary Care Physicians.
High Quality Care For All – NHS Next Stage Review Final Report41are agreed by the individual and alead professional. 7235. Over the next two years, everyone of the 15 million people withone or more long-term conditionsshould be offered a personalisedcare plan, developed, agreed andregularly reviewed with a named leadprofessional from among the teamof staff who help manage their care.The lead professional takes a leadwithin the care team for advisingthe patient on how best to accessthe care that the plan sets out. Forpeople with a serious mental illness,the ‘care programme approach’(CPA) has pioneered this approach. 73Primary care trusts and localauthorities have the responsibilityto ensure that all this is achieved, aswell as offering a choice of treatmentsetting and provider.36. Increased control will not be limitedto those being cared for, but willalso extend to carers. A new strategyhas been published, setting out theGovernment’s plans for supportingcarers. 7437. Achieving the strong partnershipthat characterises personalised careis only possible through greater‘health literacy’. Too few peoplehave access to information abouttheir care or their own care record.72 This more personalised and joint approach extendsthe original commitment to care plans in the Ourhealth, our care, our say White Paper.73 Department of Health, Refocusing the CareProgramme Approach, March 2008.74 Department of Health, Carers at the heart of21st century families and communities, June 2008.We will change this. We will expandthe educational role of the NHSChoices website. We will introduceHealthSpace online from next year,enabling increasing numbers ofpatients to securely see and suggestcorrections to a summary of theircare records, to receive personalisedinformation about staying healthy,and to upload the results of healthchecks for their clinician(s) to see. 7538. All patients will have a right to seethe information held about them,including diagnostic tests. We willensure that patients’ right to accesstheir own health records is clearby making this part of the NHSConstitution.Greater influence over resources39. We will increase the influence thatpatients have over NHS resources.For hospitals, resources alreadyfollow the choices that patients makethrough the Payment by Resultssystem. 76 We will strengthen thisby reflecting quality in the paymentmechanism and increasing individualcontrol.40. First, we will make payments tohospitals conditional on the qualityof care given to patients as wellas the volume. A range of qualitymeasures covering safety (includingcleanliness and infection rates),clinical outcomes, patient experience75 Further details on our plans for information areaddressed in the Health Informatics Review, whichwill be published shortly.76 In 2008/09, over 60 per cent of the averagehospital’s income is through Payment by Results.
42 3: High quality care for patients and the public3and patient’s views about the successof their treatment (known as patientreportedoutcome measures orPROMs) will be used. 7741. This ‘Commissioning for Quality &Innovation’ (CQUIN) scheme willencourage all NHS organisationsto pay a higher regard to quality.The scheme will build uponbest practice found in the NHSand internationally. 78 It will be asimple overlay to the Payment byResults system, forming part ofcommissioning contracts. Fundingwill be freed up through reducingthe tariff uplift from 2009 to givecommissioners dedicated space topay for improved outcomes. Providerswill be rewarded in the first yearfor submitting data. From no laterthan 2010, payments will rewardoutcomes under the scheme. Thescheme will be flexible to suit localcircumstances. Where PCTs wantto go faster, they will be able toapply the principles as soon as theywish. The scheme will be subject toindependent evaluation so that itimproves as it matures.42. Second, we will go even further inempowering individual patients.Learning from the experience inboth social care and other healthsystems, and in response to theenthusiasm we have heard fromlocal clinicians, we will explore thepotential of personal budgets, togive individual patients greatercontrol over the services they receiveand the providers from whichthey receive services. 79 Personalhealth budgets are likely to workfor patients with fairly stable andpredictable conditions, well placedto make informed choices abouttheir treatment; for example, someof those in receipt of continuing careor with long-term conditions. Witha view to national roll out, we willlaunch a national pilot programmein early 2009, supported by rigorousevaluation. This will enable the NHSand their local authority partners totest out a range of different models.43. The budget itself may well be held onthe patient’s behalf, but we will pilotdirect payments where this makesmost sense for particular patientsin certain circumstances. We willlegislate to enable these directpayments.44. The programme will be designedwith NHS, local authority, carerand patient group partners, withclear rules. We will ensure thatthe programme fully supportsthe principles of the NHS as acomprehensive service, free at thepoint of use. It will be voluntary –no one will ever be forced to havea budget, and for those that chooseto, there will be tailored support77 Department of Health, The NHS in England:Operating Framework 2008/9, December 2007.78 NHS North West have introduced a scheme to payfor performance.79 Members of NHS Yorkshire and Humber area’sclinical working group on long term conditionsadvocated exploring personal budgets inhealthcare.
High Quality Care For All – NHS Next Stage Review Final Report43to meet their different needs. Theprogramme will be underpinned bysafeguards so that no one will everbe denied treatment as a result ofhaving a personal budget, and NHSresources will be put to good use,with appropriate accountability.Partnership focused on people45. Partnership working between theNHS, local authorities and socialcare partners will help to improvepeople’s health and wellbeing, byorganising services around patients,and not people around services. Thiswill lead to a patient-centred andseamless approach. This is importantnot only for people regularly usingprimary, community and socialcare services, but will also helppeople’s transition from hospitalsback in to their homes. It will alsoreduce unnecessary re-admissionsin to hospitals. In addition localNHS organisations should work inpartnership with the local authority,3rd sector and private sectororganisations, patients and carersto implement the Putting PeopleFirst transformation programme forsocial care. 80 This programme setsout the Government’s vision forthe personalisation of social care. Itaims to improve people’s health andwellbeing through new mechanismssuch as personal budgets.80 Putting People First, A shared vision andcommitment to the transformation of adult socialcare, HM Government, December 2007.Ensuring access to the mosteffective treatments46. Patients want the most effectivetreatments, and staff want to beable to provide them. As the NHSbecomes more personal, patients andthe public want to be assured thatthe most clinically and cost effectivetreatments are available everywhere.During this Review, patients and thepublic were very clear that they hadzero tolerance for variations in accessto the most effective treatments.The National Institute for Health andClinical Excellence (NICE), establishedin 1999, has developed a worldwidereputation for its work in evaluatinghealth interventions. It has highlyregarded, transparent processes forassessing new, licensed drugs andmedical technologies to determineclinical and cost effectiveness.47. It has sometimes taken too long forNICE appraisal guidance to be madeavailable on newly licensed drugs.Guidance has often been publishedtwo years or more after a new drug’slaunch, though NICE has now put inplace a faster appraisal process forkey new drugs which enables it toissue authoritative guidance on themwithin a few months of their UKlaunch. Whilst all primary care trustshave a legal duty to fund drugs thathave been positively appraised byNICE, we recognise that patients andthe public are concerned that thereremains unexplained variation in theway local decisions are made on thefunding of new drugs before theappraisal takes place, or where noguidance is issued.
44 3: High quality care for patients and the public348. We will take steps to end this socalled‘postcode lottery’ for newdrugs and treatments. Throughthe NHS Constitution we will makeexplicit the right of NHS patientseverywhere to positively NICEappraiseddrugs and treatments,where their doctor judges that thesewould be of benefit. The Constitutionwill also make clear the right ofpatients to expect rational localdecisions on funding of new drugsand treatments. Open and honestexplanation will be due if the localNHS decides not to fund a drug ortreatment that patient and clinicianfeel would be appropriate.49. Furthermore, we will work withNICE to enable them to produceconsistently fast guidance onsignificant new drugs. This willbe achieved by making furtherimprovements to the topic selectionand appraisal process. It will meanthat NICE can issue the majority ofits appraisal guidance within a fewmonths of a new drug’s launch.50. In addition, the Secretary of Statefor Health has recently asked theNational Cancer Director, ProfessorMike Richards CBE, to review policyrelating to patients who choose topay privately for drugs not fundedon the NHS. This specifically targetedreview, to report later this year, willmake recommendations on whetherand how policy or guidance could beclarified or improved.51.Looking to the future, we willstrengthen the horizon scanningprocess for new medicines indevelopment. We will involve theindustry systematically to supportbetter forward planning and todevelop ways of measuring theuptake of clinically and cost effectivemedicines once introduced. Fornew clinical technologies, we willsimplify the way in which they passfrom development into wider use bycreating a single evaluation pathway,and will develop ways to benchmarkand monitor their successful uptake.Keeping patients as safe as possible52. Continuously improving patientsafety should be at the top of thehealthcare agenda for the 21 stcentury. The injunction to ‘dono harm’ is one of the definingprinciples of the clinical professions,and as my Interim Report madeclear, safety must be paramountfor the NHS. Public trust in theNHS is conditional on our ability tokeep patients safe when they are inour care.53. In recent years, with additionalinvestment, the NHS has focusedon raising levels of cleanlinessand reducing rates of healthcareassociated infections, includingthrough the measures set out inmy Interim Report. 81 Today, rates ofMRSA and C. difficile are falling –but we must continue to combathealthcare associated infections. 82For that reason, we have recentlyannounced a tough but fair regime81 Darzi, Our NHS, Our Future: Interim Report,October 2007.82 For more Information see the DH publicationThe Quarter: Quarter 4 2007-08.
High Quality Care For All – NHS Next Stage Review Final Report45that robustly deals with any failuresof safety. 83 Furthermore, the newhealth and adult social care regulator,the Care Quality Commission(CQC), will be able to use its newenforcement powers in relation toinfections from April 2009. 84 This is afull year before the new powers willbe available to it in relation to otherquality and safety requirements.54. Infections are only one area whereaction is needed. Since 2003, wehave made great progress on thereporting of safety incidents. TheNational Reporting and LearningSystem (NRLS) has received twomillion reports of adverse incidentsranging from the very minor to theextremely serious. Safety incidentscan involve a wide array of factors,from infrastructure, training,treatment protocols, procedureand communication to simpleadministrative errors. Safety is theresponsibility of all staff, clinical andnon-clinical.55. Building on Safety First, 85 the nextstage is to implement systematicimprovement, locally, regionallyand nationally. The National PatientSafety Campaign is being launched,led by the service. From April 2009the NPSA will run an additional,dedicated national patient safetyinitiative to tackle central linecatheter-related bloodstreaminfections, drawing lessons froma remarkably successful Michiganinitiative on the same topic. 86 TheNPSA will run regular patient safetyinitiatives like this in future.56. In some parts of the United States,events that are serious and largelypreventable such as ‘wrong-site’surgery have been designated ‘NeverEvents’, and payment withheld whenthey occur. The NPSA will work withstakeholders in this country to drawup its own list of ‘Never Events’.From next year, PCTs will choosepriorities from this list in their annualoperating plan.Conclusion57. High quality care is care wherepatients are in control, haveeffective access to treatment, aresafe and where illnesses are not justtreated, but prevented. These aremanifestations of high quality care– there is much more to be doneto place quality right at the heart ofthe NHS.86 Hales BM, Pronovost PJ, The checklist – atool for error management and performanceimprovement. J Crit Care 2006;21(3):231-5and Berenholtz SM, Pronovost PJ, Lipsett PA,et al. Eliminating catheter-related bloodstreaminfections in the intensive care unit. Crit Care Med2004;32(10):2014-20.83 Department of Health, Developing the NHSPerformance Regime, June 2008.84 Subject to the Parliamentary passage of thecurrent Health and Social Care Bill.85 Safety First, A report for patients, clinicians andhealthcare managers, Department of Health,December 2006.
4Quality at the heart ofeverything we doHigh quality care throughout the NHSA patient from Cheltenham and aphysiotherapist at the National SpinalInjuries Centre at Stoke MandevilleHospital, Aylesbury
High Quality Care For All – NHS Next Stage Review Final Report474Quality at the heart of everything we doHigh quality care throughout the NHSIntroduction1. Having considered what highquality care looks like for patientsand the public, we need to thinkhow it becomes integral to theNHS. My Interim Report containedthe message that the NHS has anunprecedented opportunity to focuson quality and that this opportunityshould be seized. 87 The visiondocuments show the enthusiasmof frontline clinicians to take up thequality challenge.2. If quality is to be at the heartof everything we do, it must beunderstood from the perspectiveof patients. Patients pay regardboth to clinical outcomes and theirexperience of the service. Theyunderstand that not all treatmentsare perfect, but they do not acceptthat the organisation of their careshould put them at risk. For thesereasons, the Review has found thatfor the NHS, quality should includethe following aspects: 88• Patient safety. The firstdimension of quality must be thatwe do no harm to patients. Thismeans ensuring the environment issafe and clean, reducing avoidableharm such as excessive drug errors87 Darzi, Our NHS, Our Future: Interim Report,October 2007.88 See Darzi, A. Quality and the NHS Next StageReview, Lancet.or rates of healthcare associatedinfections.• Patient experience. Quality ofcare includes quality of caring.This means how personal careis – the compassion, dignity andrespect with which patients aretreated. It can only be improvedby analysing and understandingpatient satisfaction with their ownexperiences.• Effectiveness of care . Thismeans understanding successrates from different treatmentsfor different conditions. Assessingthis will include clinical measuressuch as mortality or survival rates,complication rates and measuresof clinical improvement. Just asimportant is the effectivenessof care from the patient’s ownperspective which will be measuredthrough patient-reported outcomesmeasures (PROMs). Examplesinclude improvement in painfreemovement after a jointreplacement, or returning to workafter treatment for depression.Clinical effectiveness may alsoextend to people’s well-being andability to live independent lives.3. Reforms have improved qualityin terms of patient safety andeffectiveness of care. For instance,the introduction of standards
48 4: Quality at the heart of everything we do4through National Service Frameworkshas led to major progress on tacklingillnesses such as cancer and heartdisease. Conversations about qualitytake place in multi-disciplinary teamsrather than in corridors. Independentperformance assessment andregulation of providers has beenintroduced. The positive impact ofthese reforms has been noted byindependent commentators suchas the Nuffield Trust. 894. Nevertheless, it is also true thatprogress has been patchy, particularlyon patient experience. The localclinical visions found unacceptableand unexplained variations in theclinical quality of care in every NHSregion. 90 They identified importantchanges that need to be made toraise standards and ensure all servicesare high quality. The NHS has tokeep moving forward to make surepatients benefit from new treatmentsand technologies.5. In my experience, providing highquality care leads to professionalpride, and focusing on improving itenergises and motivates all NHS staff,clinical and non-clinical alike. I believewe can use that energy and make theachievement of high quality of carean obsession within the NHS. To dothis will require seven steps, building89 S. Leatherman and K. Sutherland, The Quest forQuality: Refining the NHS Reforms, Nuffield Trust,May 2008.90 See for instance NHS East of England, Towardsthe best, together, May 2008, which notes thehuge variation in caesarean section rates betweenhospitals (from 15% to 27%) and the bigvariation in consultant level psychology staffacross the region.on the cornerstone of existing localclinical governance:• Bring clarity to quality. Thismeans being clear about whathigh quality care looks like in allspecialties and reflecting this in acoherent approach to the settingof standards.• Measure quality . In order to workout how to improve we need tomeasure and understand exactlywhat we do. The NHS needs aquality measurement frameworkat every level.• Publish quality performance.Making data on how well weare doing widely available tostaff, patients and the publicwill help us understand variationand best practice and focus onimprovement.• Recognise and reward quality .The system should recognise andreward improvement in the qualityof care and service. This meansensuring that the right incentivesare in place to support qualityimprovement.• Raise standards . Quality isimproved by empowered patientsand empowered professionals.There must be a stronger rolefor clinical leadership andmanagement throughout the NHS.• Safeguard quality . Patients andthe public need to be reassuredthat the NHS everywhere isproviding high quality care.Regulation – of professions and
High Quality Care For All – NHS Next Stage Review Final Report49of services – has a key role to playin ensuring this is the case.• Stay ahead. New treatments areconstantly redefining what highquality care looks like. We mustsupport innovation to foster apioneering NHS.Bringing clarity to quality6. We will begin by changing the waystandards are set, to bring greaterclarity to what high quality carelooks like. For everyone workingin healthcare, keeping up withbest practice is a challenging task.The current breadth and depthof guidance is impressive butalso daunting. National ServiceFrameworks have proved effective,but sometimes at the expense ofsecuring improvement more widelyacross all areas of care and thespectrum of clinical conditions. Manybodies undertake standard setting,and what is desirable versus whatis mandatory is often too hard tounderstand. In addition, NHS stafftell us that the knowledge andinformation they need to deliverexcellent care can be too hard to find.7. We will address these problemsby transforming the role of NICE,building on its successes andinternationally acclaimed reputation.From 2009, it will expand thenumber and reach of national qualitystandards, either by selecting thebest available standards (includingthe adoption of the relevant parts ofNational Service Frameworks) or byfilling in gaps. NICE will manage thesynthesis and spread of knowledgethrough NHS Evidence – a new, singleportal, through which anyone will beable to access clinical and non-clinicalevidence and best practice, bothwhat high quality care looks like andhow to deliver it. Greater clarity onstandards, and where to go to findthem, will support the commissioningand uptake of the most clinically andcost effective diagnostics, treatmentsand procedures.8. NICE will continue to work openlyand collaboratively in partnership atnational level and with frontline staff.For frontline clinicians, working withNICE is already considered a valuableopportunity for clinical professionaldevelopment. In the next stage ofits development, I would like to seeNICE reach out even more proactivelyto local clinical communities as wellas national ones. A key enablerof this will the establishment of afellowship programme. I hope thatmany of the 2,000 frontline cliniciansthat led this Review locally will applyfor fellowship, and that many otherswill come forward too.Measuring quality9. The next stage in achieving highquality care, requires us to unlocklocal innovation and improvementof quality through information –information which shows clinicalteams where they most need toimprove, and which enables themto track the effect of changes theyimplement. After all, we can only besure to improve what we can actuallymeasure.10. It is important that we have anational quality framework thatenables us to publish comparable
50 4: Quality at the heart of everything we do4information on key measures. Withthe help and support of frontlineclinicians, we have begun to identifycomparable measures that arecurrently used by different parts ofthe service today, and will bring themtogether into an integrated nationalset. These national metrics will bedeveloped through discussion withpatients, the public and staff. Wewill announce the first set of qualityindicators that will be used nationallyby December 2008. And althoughwe will begin with acute services,from next year, we will also developand pilot a quality framework forcommunity services.11. The national metrics will beimportant, but it will be critical thatlocal NHS organisations should signup to the concept of quality metricsand feel motivated to augment thenational indicators with their ownmeasurements of quality. Our aimis for NHS organisations to freelydevelop the measures that will besthelp them to review the quality ofthe services they offer regularly.12. Within organisations, we know thata defining characteristic of highperforming teams is their willingnessto measure their performanceand use the information to makecontinuous improvements. We wantall clinical teams to follow this bestpractice and so we will supportthem by working in partnership withthe professional bodies, specialistsocieties and universities to developa wider range of useful local metrics,than the national framework. We willalso develop ‘Clinical Dashboards’which will present selected nationaland locally developed measures in asimple graphical format as a tool toinform the daily decisions that drivequality improvement.13. Dashboards are being piloted byfrontline NHS staff in three locations:• In an East London A&Edepartment, the dashboardpresents information, updatedevery 15 minutes, about how soonpatients are seen, assessed andget results from tests, and aboutpatient satisfaction. The dashboardis used by staff and is displayedprominently in the patients’waiting area.• In Nottingham, a urology surgicalteam is using the dashboard topresent information on length ofstay, complications and averageoperation length.• In Bolton, a GP practice is workingwith the local A&E to collect anddisplay information on the numberof patients attending A&E and outof-hoursservices.14. Our goal is that every provider ofNHS services should systematicallymeasure, analyse and improvequality. They will need to developtheir own quality frameworks,combining relevant indicators definednationally, with those appropriate tolocal circumstances. This will includequality measures that reflect thevisions for improved services that areat the core of this Review.
High Quality Care For All – NHS Next Stage Review Final Report5115. In primary care, the Quality andOutcomes Framework alreadyprovides a range of valuable data onquality, particularly for the qualityof care for people with long-termconditions. Chapter 3 set out howwe will ensure GP practices willhave incentives and opportunitiesto engage in prevention activity. Wewill introduce a new strategy fordeveloping the Quality and OutcomesFramework, which will includean independent and transparentprocess for developing and reviewingindicators. We will discuss with NICEand with stakeholders includingpatient groups and professionalbodies how this new process shouldwork. We will discuss how to reducethe number of organisational orprocess indicators, and refocusresources on new indicators ofprevention and clinical effectiveness.We will explore the scope to givegreater flexibility to PCTs to workwith primary healthcare teams toselect quality indicators (from anational menu) that reflect localhealth improvement priorities.Publishing quality performance16. Commitments have been madeover a number of years to publishinformation on clinical effectiveness. 91Too often these commitments havebeen held up by uncertainties aboutwhat was needed to make progress91 The publication of surgical outcomes wasrecommended by the then Secretary of State forHealth’s Response to the Bristol Royal InfirmaryInquiry on 18 July 2001, who acknowledged thatthis would take time as such data needed to be“robust, rigorous and risk-adjusted.”and disagreements about who shouldbe in charge. This is unacceptable.We should be seeking to create amore transparent NHS. It may be acomplex task, but we should developacceptable methodologies and thencollect and publish information sothat patients and their carers canmake better informed choices, clinicalteams can benchmark, compareand improve their performance andcommissioners and providers canagree priorities for improvement.17. Therefore, to help make qualityinformation available, we will require,in legislation, healthcare providersworking for or on behalf of the NHSto publish their ‘Quality Accounts’from April 2010 – just as they publishfinancial accounts. These will bereports to the public on the quality ofservices they provide in every serviceline – looking at safety, experienceand outcomes. Easy-to-understand,comparative information will beavailable on the NHS Choices websiteat the same time. The Care QualityCommission will provide independentvalidation of provider andcommissioner performance, usingindicators of quality agreed nationallywith DH, and publish an assessmentof comparative performance.18.The CQC will publish an annualreport to Parliament on the provisionof NHS care within England. Buildingon the strengths of the HealthcareCommission and the Commission forSocial Care Inspection, the CQC willtherefore provide assurance for thepublic that information about thequality of care is reliable.
52 4: Quality at the heart of everything we do419. I know that patients, staff and thepublic all want an NHS that is asgood as any healthcare system in theworld. Meeting this aspiration willrequire us to understand how weperform compared to other advancedhealthcare systems. So we will workwith other Organisation for EconomicCooperation & Development (OECD)countries and with the best academicinstitutions in the world and draw onour new national quality frameworkto agree some internationallycomparable measures.Recognising and rewardingquality improvement20. The NHS should recognise andreward quality improvement. Thismeans putting the right incentives inplace to support high quality care.21. We will ensure that from April 2009the payment system for providersof NHS services is improved so thatit better reflects clinical practice,recognises complexity of care –including the most specialisedservices – and supports innovation. 92As outlined in Chapter 3, theCommissioning for Quality andInnovation Scheme (CQUIN) will alsosupport local drives for improvement,concentrating on those aspectsof quality that most need localattention.22. We also want organisations thatreceive NHS funds to be able toplan for long-term improvements92 For more on the new version of HealthcareResource Groups (HRG4), which will be used aspart of the Payment by Results funding system,please see www.ic.nhs.ukto patient care and ensure bestvalue. For that reason, we will setout projections for tariff uplift andefficiency gains on a multi-year basis,aligning with future Spending Reviewperiods and PCT allocations cycles.23. Finally, to ensure we apply theseprinciples as widely as possible, wewill also extend payment and pricingsystems to cover other services. Forexample, for mental health services,we will develop national currenciesavailable for use from 2010/11.This will allow the comparisonand benchmarking of mentalhealth services, supporting goodcommissioning.Raising standards24. The locally owned nature of thisReview has reinforced my belief thatchange is most effective not onlywhen it responds clearly to patientneeds but also when it is drivenby clinicians based on their expertknowledge of conditions andcare pathways. Change has notalways been managed this way inthe NHS. We will therefore put astrong clinical voice at every level inthe NHS and we will increase ouroverall capacity to act on standardsand information that support qualityimprovement. Where we haveempowered local clinicians, they haverisen to the challenge and deliveredreal improvements for their patients.25. We will support clinical teamsand clinical directors to developtheir practice through peerreview, continuing professionaldevelopment and professional
High Quality Care For All – NHS Next Stage Review Final Report53revalidation. In secondary care,pioneering accreditation schemeshave been developed in psychiatricspecialties and, with our support,in radiology. The Royal College ofGeneral Practitioners is developingan accreditation scheme for GPpractices, which is now being pilotedand if appropriate, will be adoptednationally by 2010.26. Locally, primary care trusts, on behalfof the populations that they serve,should challenge providers to achievehigh quality care. This will requirestronger clinical engagement incommissioning. This must go beyondpractice-based commissioning andprofessional executive committees toinvolve all clinician groups in strategicplanning and service developmentto drive improvements in healthoutcomes.27. This will be achieved throughthe World Class Commissioningprogramme, which will holdprimary care trusts to accountfor the involvement of the fullrange of informed clinicians. Theassurance system that has beendeveloped will draw on evidenceincluding a feedback survey fromclinicians, the quarterly practicebased commissioning survey,practice-based commissioninggovernance arrangements and thefive year strategic plan. This will besupplemented by interviews betweenthe PCT board and a panel ofindependent experts, one of whomwill be a clinician.28. Senior clinical leadership at aregional level is currently providedby a Regional Director of PublicHealth, and a Nurse Director in eachstrategic health authority. By April2009, the senior clinical leadershipwithin SHAs will be enhanced withthe appointment of new, dedicatedSHA Medical Directors. Each SHA willbring forward proposals for medicaldirectors that take account of theindividual circumstances of the SHA.29.The SHA medical directors willbe responsible for overseeingimplementation of the local clinicalvisions and providing medicalleadership to NHS organisations intheir area. They will work alongsideregional directors of public healthand work closely with professionalexecutive committee chairs. Theywill have professional accountabilityto the NHS Medical Director at theDepartment of Health.30. The senior clinical leadership teamwithin each SHA will be supportedby a SHA Clinical Advisory Group,appointed through competition. EachSHA will make proposals on how bestto implement these arrangements.31. The new arrangements will helpsustain and support the strong clinicalvoice exemplified through this Review.32. We will also ask each SHA to establisha formal Quality Observatory, buildingon existing analytical arrangements,to enable local benchmarking,development of metrics andidentification of opportunities to helpfrontline staff innovate and improve
54 4: Quality at the heart of everything we do4the services they offer. I expect thateach Quality Observatory will wishto make its information availablethrough portals such as NHSEvidence, to be run by NICE, andthe NHS Choices website.33. The Department of Health willcontinue to have a role in ensuringthat the NHS recognises and preparesfor national clinical priorities. We willestablish a National Quality Boardto provide strategic oversight andleadership on quality. It will overseethe work to improve quality metrics,advise the Secretary of State on thepriorities for clinical standards set byNICE, and make an annual reportto the Secretary of State on thestate of quality in England using theinternationally agreed comparablemeasures. The first report will bepublished by June 2009. It shoulddraw from output of reviews andreports published by the Care QualityCommission and its predecessoron healthcare, the HealthcareCommission.34. To demonstrate that quality isthe responsibility of clinicians andmanagers throughout the system,the Board will be chaired by theNHS Chief Executive. Membershipwill include representation from thevarious national statutory bodiesthat make up the national ‘qualitylandscape’ for health and social care– including professional and statutorybodies. The aim of the Board will beto bring together all those with aninterest in improving quality, to alignand agree the NHS quality goals,whilst respecting the independentstatus of participating organisations.Safeguarding quality: the role ofintelligent regulation35. Action to underpin this drive forimproved quality through toughregulation is already underway. Thefirst step has been to enhance therole of independent regulation,building on the achievements ofexisting regulators. The new CareQuality Commission will have astronger focus on compliance andmore flexible enforcement powers.It will ensure compliance withregistration requirements for safetyand wider quality that all healthand adult social care providers willbe expected to meet in order to bepermitted to deliver services. It willprovide independent information andassurance that systems for safety andquality are in place and working well,and it will help providers identifyareas in need of improvement.36. We have recently consulted onproposals that the new CareQuality Commission in time shouldregulate safety and quality for allGP and dental practices. 93 Thiswould mean that, for the firsttime, any organisation providingprimary medical or dental care willbe subject to a consistent set ofquality standards. The approachmust be light-touch, risk-based andproportionate. The CQC will workwith patients and the public, theNHS and the professions to developthis approach in practice and todetermine where best to deploy itsregulatory focus. And in doing so,the CQC will want to take accountof the contribution that emerging93 Department of Health, The future regulation ofhealth and adult social in England, 25 March 2008.
High Quality Care For All – NHS Next Stage Review Final Report55professionally led accreditationschemes can play, both in primarycare and elsewhere in health andsocial care.Staying ahead: a pioneering NHS37. Clinical practice is constantlyimproving, offering newopportunities to improve the qualityof care. This means that if quality isreally at the heart of everything wedo, accepting, embracing and leadingchange is an imperative, not anoption. Innovation must be central tothe NHS. We established the HealthInnovation Council to championinnovation for the NHS and help usdevelop the innovation proposals inthis report.38. We will continue to transform healthresearch in the NHS by implementing,consolidating and building onthe Government’s strategy, BestResearch for Best Health, for thebenefit of patients and the public.Our researchers have made a greatcontribution and will continue to doso. However, too often innovationhas been defined narrowly, focusingsolely on research, when in factinnovation is a broader concept,encompassing clinical practice andservice design. Service innovationmeans people at the frontline findingbetter ways of caring for patients –improving outcomes, experiencesand safety. In this country, we have aproud record of invention, but we lagbehind in systematic uptake even ofour own inventions. 9494 See Darzi, Healthcare for London: A Frameworkfor Action, Case for Change reason six, 200739. We want best practice everywhereas the platform from whichinnovation can flourish. Thismeans doing away with outdatedpractice. Clearer standards froman expanded NICE will supportcommissioners to secure the bestcare for patients by disinvesting fromsuperseded treatments, so ensuringNHS resources are focused on themost clinically and cost effectiveapproaches.40. To support local efforts to addressunexplained variation in quality anduniversalise best practice, we willstart to pay prices that reflect thecost of best practice rather thanaverage cost. This will be enabledthrough the Best Practice Tariffsprogramme, which we will introducewhere the evidence of what is bestpractice is clear and compelling.We will start in 2010/11 with fourhigh-volume areas where there issignificant unexplained variation inpractice: cataracts, fractured neck offemur, cholecystectomy, and strokecare. We will discuss this proposalwith clinicians and give furtherinformation on these areas later thisyear so that providers can plan inadvance of tariff changes. The BestPractice Tariffs programme will berigorously evaluated, not least toensure that it is working for all thepartners involved in the delivery ofcare, and if successful, expanded infuture years.41. Innovation will be driven regionallyby strategic health authorities whowill have a new legal duty to promoteinnovation. We will support frontline
56 4: Quality at the heart of everything we do4innovation through the creation of asubstantial new regional innovationfunds held by SHAs. The funds’purpose will be to identify, growand diffuse innovation. They will besupported and advised nationally,drawing on expertise and experiencefrom those with a track record infund management to ensure goodrates of return on our investment inthe future. An independent expertpanel will assess local applicationsand make awards. In addition, wewill create new prizes for innovationsthat directly benefit patients andthe public. They will help foster anenterprise and innovation culturewithin the NHS. The prizes will bedesigned to engage a wide range ofNHS staff and an expert panel andwill be focused on tackling someof the major health challenges,such as radical breakthroughs inthe prevention and treatment oflifestyle diseases.42. We want to foster a pioneeringhealth service that makes bestuse of the talents of NHS staff,the higher education sector andindustry. International evidence fromcontinental Europe, North Americaand the Far East, has demonstratedthat patients benefit by bringingtogether the talents of differentsectors. Their skills are harnessed indeveloping pioneering treatmentsand service models for patients. Wewill enable the stronger partnershipsthat bring these benefits throughcreating a new opportunity – HealthInnovation and Education Clusters.43. Health Innovation and EducationClusters will bring together manypartners, across primary, communityand secondary care, universitiesand colleges, and industry. They willbe collaborations that set sharedstrategic goals for the benefitof member organisations. Theirmembers will run joint innovationprogrammes that reflect their localneeds and distinctiveness. They willalso promote learning and educationbetween their members. BringingNHS organisations and highereducation institutions togetherwill enable research findings to beapplied more readily to improvepatient care.44. Over time, in keeping with theiraspirations and abilities, it willbe possible for these clustersto be commissioned to providepostgraduate education and trainingof all healthcare professionals. Thiswill help ensure that trainees get thebreadth, depth and quality of trainingand teaching to provide the highquality care to which the NHS aspires.45. Recognising the diversity of expertiseand interests, these clusters will notbe defined or imposed nationally,but will be enabled to emerge locally.They will build upon and reinforcesuccessful models of collaborationthat are already found in the NHS.We will invite applications fromDecember 2008 for assigned statusand funding and will award matchedfunding to proposals that deliverclear benefits to patients, as judgedby an expert peer review process.
High Quality Care For All – NHS Next Stage Review Final Report5746. We also intend to foster AcademicHealth Science Centres (AHSCs)to bring together a small numberof health and academic partnersto focus on world-class research,teaching and patient care. Theirpurpose is to take new discoveriesand promote their application inthe NHS and across the world.Centres such as these will be wherebreakthroughs are made and thenpassed directly on to patients onthe ward. There is no pre-definednumber, although we have heardinterest expressed by five to 10organisations already.47.The best and most successful AHSCswill have the concentration ofexpertise and excellence that enablesthem to compete internationally.For these organisations, the peerset will not be simply this country orour European neighbours. They willcompete globally with establishedcentres such as those in the UnitedStates, Canada, Singapore, Swedenand the Netherlands.48. We will define the criteria forbecoming an Academic HealthScience Centre (AHSC). In recognitionof the global dimension, we willestablish an international panel ofexperts to award this status. Thiswill objectively determine whetherorganisations that aspire to this statushave the appropriate concentrationof expertise and excellence to be ableto compete internationally. Thosewho have self-designated AHSCstatus will be subject to review bythe international panel of experts.49. The potential of AHSCs to deliverresearch excellence and improvepatient care and professionaleducation is tremendous. Cleargovernance arrangements withacademe, which ensure this worksfor both patients and the NHS, willbe very important. A number ofgovernance models have alreadyemerged to suit local circumstances;that is preferable to the impositionof a single model. Our approach willtherefore be broadly permissive; weare open to proposals for differentforms of governance on a case-bycasebasis, including, potentially,changing legislation where thiswould help an AHSC to achievethe optimal governance model tosupport its success. We will workwith interested organisations todevelop these over the next year.Conclusion50. If everyone, from the hospital ChiefExecutive to the GP receptionist isprimarily focussed on achieving highquality care for patients, we will havesucceeded. Central initiatives, fromfostering innovation to encouragingquality reporting can play their part.However, ultimately if high qualitycare is to become more than an ideal,we need to free the local NHS toconcentrate on quality.
5Freedom to focuson qualityPutting frontline staff in controlA senior sister from the NeonatalIntensive Care unit at the Chelseaand Westminster Hospital, London
High Quality Care For All – NHS Next Stage Review Final Report595Freedom to focus on qualityPutting frontline staff in controlIntroduction1. Our quality agenda can only succeedif the frontline NHS staff are giventhe freedom to use their talents. I,and my fellow clinicians, come towork to deliver health care. We try toimprove our practice, but we needthe freedom and opportunity to doso. When given that freedomthrough the process of this review,2,000 clinicians, health and socialcare staff seized the opportunity todefine the future of the NHS.Unlocking talents2. Healthcare is delivered by a team. Theteam includes clinicians, 95 managerialstaff and those in supporting roles.All members of the team are valued.The sense of a shared endeavour –that all of us matter and standtogether – was crucial in theinception of the NHS.3. Every member of the team must bepulling in the same direction. Withoutthe surgery receptionist, no patientswould have appointments. Withoutthe hospital porter, there would be nopatient on the operating table. Forpatients, the team must go beyondindividual organisations – they expecteveryone in the NHS (and beyond intoother public services such as socialcare, housing, education andemployment) to work together, togive them the high quality, integratedcare that they need and want.4. In the past, the clinician’s role withinthe team has often been confined toa practitioner, an expert in theirclinical discipline. Yet frontline staffhave the talent to look beyond theirindividual clinical practice and act aspartners and leaders. In future, everyclinician has the opportunity to be a:• Practitioner: Clinicians’ first andprimary duty will always be theirclinical practice or service, deliveringhigh quality care to patients basedon patients’ individual needs. Thismeans working with patients,families and carers in deliveringhigh quality, personal care, themost effective treatments andseeking to keep people healthy aswell as treating them when theyare sick. It is an agenda thatreinforces the importance ofprofessional judgement, creativityand innovation.95 Clinicians include those staff who provide clinicalcare to patients and the public, including doctors,dentists, nurses, midwives, healthcare scientists,pharmacists, allied health professionals, clinicalsupport workers and paramedics.
60 5: Freedom to focus on quality5• Partner: Clinicians must be partnersin care delivery with individual andcollective accountability for theperformance of the health serviceand for the appropriate use ofresources in the delivery of care.Partnership requires clinicians totake responsibility for theappropriate stewardship andmanagement of finite healthcareresources. Partners will be expectedto work closely with others in thehealth service and beyond, such associal care colleagues, children’scentres and schools, to manage thebalancing of individual andcollective needs, integrating carearound patients.• Leader: Clinicians are expected tooffer leadership and, where theyhave appropriate skills, take seniorleadership and management postsin research, education and servicedelivery. Formal leadershippositions will be at a variety oflevels from the clinical team, toservice lines, to departments, toorganisations and ultimately thewhole NHS. It requires a newobligation to step up, work withother leaders, both clinical andmanagerial, and change the systemwhere it would benefit patients.5. These three ways in which clinicianscan use their talents are already inevidence in parts of the NHS andinternationally. 96 The best work on96 The formulation “practitioner, partner, leader”builds upon international experience bestexemplified by Kaiser Permanente’s approach toclinical leadership in the United States.professionalism is also acknowledgingclinicians’ wider roles in the NHS. 976. The exact balance betweenpractitioner, partner and leader willbe different, depending on theprofessional role undertaken. Forthose in formal leadership roles, suchas clinical directors, a majority oftheir time is spent as leaders. Formany, clinical practice will continueto dominate – though they will stillneed to work with others as partnersand show the necessary leadershipto keep practice up-to-date anddeliver the best possible care fortheir patients.7. What is clear is that this newprofessionalism, acknowledgingclinicians’ roles as partners andleaders, gives them the opportunityto focus on improving not just thequality of care they provide asindividuals but within theirorganisation and the whole NHS. Weenable clinicians to be partners andleaders alongside manager colleaguesthrough the following principles:• Giving greater freedom to thefrontline. We will continue thejourney of setting frontline staff,both providers and commissioners,free to use their expertise, creativityand skill to find innovative ways toimprove quality of care for patients.97 For examples of where this is already taking place,see Doctors in Society (Royal College of Physicians2005) and Understanding Doctors: HarnessingProfessionalism (King’s Fund and Royal College ofPhysicians 2008).
High Quality Care For All – NHS Next Stage Review Final Report61• Creating a new accountability.Setting NHS staff free from centralcontrol requires a new, strongeraccountability that is rooted in thepeople that the NHS is there toserve. It means the service shouldlook out to patients and thecommunities they serve not upthe line.• Empowering staff . Professionalsneed to be empowered to makethe daily decisions that improvequality of care and we will enablethis to happen.• Fostering leadership for quality.All these steps together create theright environment for high qualitycare to happen, but we need tofurther develop clinical andmanagerial leadership.Giving greater freedom tothe frontlineAcute, mental health, andambulance trusts8. The journey of setting NHSorganisations free from centraldirection began with the creation ofNHS trusts and, subsequently, NHSfoundation trusts. It continues. Ourcommitment to making acute,mental health and ambulance trustsinto NHS foundation trusts remainsstrong. It is our clear ambition that infuture hospital care will be providedby NHS foundation trusts. In order toachieve this, we will aim to acceleratethe rate at which existing NHS trustsachieve NHS foundation trust status.9. We will extend these freedoms tocommunity providers, exploring arange of options including socialenterprises and communityfoundation trusts. However, there aresome providers, for example highsecure units, where NHS foundationtrust status is not appropriate. Herewe will aim to give similar freedomsto organisations, which achieveand maintain similar levels ofgood governance and financialstability to those required of NHSfoundation trusts.10.It is important that providerorganisations enjoy these new andexisting freedoms in the context ofthe national framework. We willtherefore continue to ensure that FTsand other providers meet agreedstandards for quality of care andchoice, and take account of the newNHS Constitution.11.The freedom of NHS foundationtrusts to innovate and invest inimproved care for patients is valuableand essential. We welcome recentinitiatives that have seen some NHSfoundation trusts share the proceedsof their success with all of their staff,from the porter to the seniorclinician, and encourage more todo likewise. 98 These autonomousorganisations are ideally placed torespond to patient expectations ofhigh quality care.98 Gloucestershire Hospitals NHS foundation trustannounced that all staff would benefit from a£100 bonus, BBC Online, 14 December 2007.
62 5: Freedom to focus on quality5Community services12. We now need to give greaterfreedom to those working incommunity services. So far, they havenot had the same opportunities formore autonomy. Over a quarter of amillion nurses, midwives, healthvisitors, allied health professionals,pharmacists and others work incommunity health services. They havea crucial role to play in providingsome of the most personalised care,particularly for children and families,for older people and those withcomplex care needs, and inpromoting health and reducinghealth inequalities.13. We believe that staff working incommunity services deserve the samedeal as those working in any otherpart of the NHS. They speak withpassion about the potential for usingtheir professional skills to transformservices, but are frustrated at thehistoric lack of NHS focus on how tofree up these talents. We will supportthe development of vibrant,successful provider services thatsystematically review quality andproductivity, including new ways ofworking in partnership with others,to free up more time for patient careand to improve health outcomes.14. We will support the NHS in makinglocal decisions on the bestgovernance and organisationalmodels to support the developmentof flexible, responsive communityservices. Some primary care trustshave already done this by developingarm’s-length provider organisationsthat remain accountable to theBoard. In other areas, the NHS isexploring new approaches such ascommunity NHS foundation trusts orsocial enterprises.15. We recognise concerns aboutstaff pension rights when neworganisational arrangements arebeing introduced. Where PCTs andstaff choose to set up socialenterprise organisations, transferredstaff can continue to benefit from theNHS Pension Scheme, while theywork wholly on NHS funded work.We will support local decisionmakingby drawing together andpublishing advice on this range oforganisational options and theirimplications for issues such asgovernance, patient choice,competition and employment.16.We will also encourage and enablestaff to set up social enterprises byintroducing a staff ‘right to request’to set up social enterprises to deliverservices. PCTs will be obliged toconsider such requests, and if thePCT board approves the businesscase, support the development of thesocial enterprise and award it acontract to provide services for aninitial period of up to three years.NHS commissioners17. NHS commissioners, working withtheir local authority partners throughmechanisms such as joint strategicneeds assessments, exist to championthe interests of patients, families andthe communities in which they live toget the right care, in the right place,
High Quality Care For All – NHS Next Stage Review Final Report63at the right time. They manage thelocal health system on behalf ofpatients, the public and staff. Thework that Sir Ian Carruthers OBE hasled during this Review has shownhow commissioners can exercise theirresponsibility to secure high qualitysustainable care for their populationsincluding in rural areas through arange of innovative delivery models.The World Class Commissioningprogramme is designed to raiseambitions for a new form ofcommissioning that deliver betterhealth and well-being for thepopulation, improving healthoutcomes and reducing healthinequalities – adding life to yearsand years to life. 9918. This programme has tremendouspotential and needs to be challengingabout the capability of many of ourcommissioners and how far we havegot with practice-basedcommissioning. It must providestrong support and encouragementto PCTs to develop quickly. As part ofthis programme, where primary caretrusts have demonstrated that theyare improving health outcomes, theywill be given greater freedom overthe priorities they set and themethods, people and approachesthey employ. We will set out thesefreedoms in the autumn.19. PCTs are the leaders of the local NHS,and should be seen this way. All PCTs99 For more on world class commissioningsee Department of Health, World ClassCommissioning: Competencies and Vision,December 2007.will be free to take the name of theirlocality, so that instead of being‘somewhere PCT’, they are ‘NHSsomewhere’, e.g. NHS Blackpool. Thisproperly reflects that they are theNHS organisation responsible andaccountable for the health of thepopulation of that area.20. We will support primary care trustsas they become World ClassCommissioners, with both local andnational development resources. Aspart of this, the Department ofHealth, on behalf of the strategichealth authorities, will establish a listof independent sector organisationsthat can help primary care trusts todevelop the capabilities of theirmanagement boards.Creating a new accountability21. With greater freedom must come anew and enhanced accountability.As the NHS achieves onceaspirational targets such as 18 weeksfrom referral to treatment, halvedinfections rates, and a maximum waitof four hours in accident andemergency, so these ambitionsbecome established as minimumstandards. In future, new andessential national challenges will bemet through robust minimumstandards and by ensuring thatnational priorities are reflected inlocal commissioning. There will be noadditional top-down targets beyondthe minimum standards.22. Our new approach to accountabilitywill be through openness on thequality of outcomes achieved for
64 5: Freedom to focus on quality5patients. Professional regulation hasensured that practitioners areaccountable to their individualpatients during their episode of care.By focusing on the overall outcome,it means that the new accountabilityis for the whole patient pathway – soclinicians must be partners as well aspractitioners. All the different parts ofthe system – different organisationsand professional groups – must stackup behind one another to achievethe best outcome for patients.23. There will be no national targets setfor quality performance, but, asexplained in Chapter 4, the outcomesachieved by every NHS organisationwill be openly available. In this way,clinicians, and the organisations theywork in, will be held to account bytheir patients, their peers and thepublic. Measuring and valuing whatmatters most to patients, the publicand staff is the way in which we willenable the NHS to make progresstowards high quality care. We believethis transparency will facilitatemeaningful conversations betweenteams and members of teams abouthow they can continuously improvethe quality of care they deliver.24. This transparency must not be limitedto acute health services. Therefore,from next year, we will develop andpilot a quality framework forcommunity services. Later this year,we will complete work on a standard,but flexible, contract to enablecommissioners to hold communityhealth services to account for qualityand health improvement. We willalso increase transparency by movingaway from ‘block contract’ funding.25. NHS commissioners will be held toaccount for the quality of healthoutcomes that they achieve for thepopulations they serve, including themost vulnerable or excluded peoplewith complex care needs. We havedeveloped a new assurance systemthat combines local flexibility withstrengthened accountability. 100 It isone nationally consistent approach,managed locally by strategic healthauthorities, and includes an annualassessment of health outcomes,competences and governance as wellas providing a commentary on theirpotential for improvement. Allprimary care trusts will haveimplemented the assurance system byMarch 2009, and the first results willbe formally published in March 2010.Empowering staff26. If clinicians are to be held to accountfor the quality outcomes of the carethat they deliver, then they canreasonably expect that they will havethe powers to affect those outcomes.This means they must be empoweredto set the direction for the servicesthey deliver, to make decisions onresources, and to make decisionson people.27. In acute care, giving nurse managersauthority and control over resourceswill lead to better, safer, cleanerwards and a higher quality patientexperience. Giving clinical directorsthe power to make decisions on theservices they offer, the appraisal andmanagement of their staff and the100 Department of Health, World ClassCommissioning Assurance System, June 2008.
High Quality Care For All – NHS Next Stage Review Final Report65way in which they spend theirbudgets will lead to better qualityoutcomes for patients. 101 Throughour new approach to ‘leadership forquality’ we will support clinicians asthey take on these roles.28. The purpose of practice-basedcommissioning is to empower familydoctors and community clinicians toassemble high quality care aroundthe needs of patients. It should putclinical engagement at the heart ofthe commissioning process. We haveheard the message, however, that ithas not lived up to this aspiration.That is why we will work with theNHS and with the professions toredefine and reinvigorate it.29.We will give stronger support topractice-based commissioning. Thismeans we will provide incentives fora broader range of clinicians to getinvolved, so that it brings familydoctors together with othercommunity clinicians and withspecialists working in hospitals todevelop more integrated care forpatients. We will distinguish moreclearly between the collaborative,multi-professional work involved incommissioning better care for GPpractice populations and the role ofGP practices in providing anenhanced range of services for theirpatients. And we will ensure thatprimary care trusts are held fully toaccount for the quality of theirsupport for practice based101 Evidence from the US shows that hospitals witha higher proportion of clinically trained managersare better managed (Source: McKinsey analysis).commissioning, including themanagement support given to PBCgroups and the quality and timelinessof data (e.g. on budgets, referralsand hospital activity).30. We will empower clinicians further toprovide more integrated services forpatients by piloting new integratedcare organisations (ICOs) bringingtogether health and social careprofessionals from a range oforganisations – community services,hospitals, local authorities andothers, depending on local needs.The aim of these ICOs will be toachieve more personal, responsivecare and better health outcomes fora local population (based on theregistered patient lists for groups ofGP practices). We will inviteproposals shortly.Fostering leadership for quality31. Greater freedom, enhancedaccountability and empowering staffare necessary but not sufficient inthe pursuit of high quality care.Making change actually happentakes leadership. It is central to ourexpectations of the healthcareprofessionals of tomorrow. There aremany routes to excellent leadershipand we do not claim to have all theanswers. But we do want people tobe able to have meaningfulconversations that transcendorganisational boundaries. That iswhy we have identified the coreelements of any approach toleadership, which we expect all thoseleading change in the NHS to beclear about:
66 5: Freedom to focus on quality5• Vision . What qualityimprovements they are trying toachieve and how it will benefitpatients and local communities.• Method. How they will makechange happen – the managementmethod they will use forimplementation, continuousimprovement and measuringsuccess.• Expectations. What the differencewill mean for people, thebehavioural change that will benecessary and the values thatunderpin it.32. As explained in the publicationLeading Local Change, 102 change inthe NHS should always be of benefitto individual patients and thepopulation as a whole, should beclinically driven and locally led,with patients, the public and staffinvolved. In the NHS constitution,we pledge to staff that they will beengaged in the decisions that affectthem. Leadership has been theneglected element of the reforms ofrecent years. That must now change.33. It is unrealistic to expect NHS staff totake on leadership without action tomake it integral to training anddevelopment. So we will exploreways to ensure that theundergraduate curricula for allmedical and nursing students reflectthe skills and demands of leadershipand working in the NHS. We will alsoensure that leadership development102 Darzi A., NHS Next Stage Review: Leading LocalChange (2008).is an integral part of modernisingcareers programmes for otherhealthcare professions.34. For those at a postgraduate orequivalent stage in their careers, wewill explore ways to ensure that boththe curricula and appraisal processesreflect the importance of learningleadership skills. For those with aparticular interest in leadership,we will support strategic healthauthorities and health innovation &education clusters to establish ClinicalLeadership Fellowships so that theyhave dedicated time to spend onenhancing their leadership skills.35. The local NHS already makesconsiderable investments inleadership development programmes,for clinicians and managers alike. Wehave heard that these can be variablein their scope and standard. That iswhy we will introduce a newstandard in healthcare leadership,the Leadership for Quality Certificate.It will operate at three levels. Level 1will be for members of clinical andnon-clinical teams with an interestin becoming future leaders. Level 2will be for leaders of team andservice lines, and Level 3 will be forsenior directors (e.g. medical,nursing, operations).36. At the most senior levels, we willidentify and support the top 250leaders in the NHS. This group willinclude both clinical and non-clinicalleaders. They will get close support intheir personal development,mentoring, and active careermanagement.
High Quality Care For All – NHS Next Stage Review Final Report6737. We will establish an NHS LeadershipCouncil which will be a system-widebody chaired by the NHS ChiefExecutive, responsible for overseeingall matters of leadership acrosshealthcare, including the 250 leaders.It will have a particular focus onstandards (including overseeing thenew certification, the development ofthe right curricula, and assurance)and with a dedicated budget, will beable to commission developmentprogrammes.38. The NHS Medical Director andNational Clinical Directors will alsowork with senior clinicians to ensurethat clinical leadership becomes astronger force within the NHS.Compared to healthcareorganisations in the US, such asKaiser Permanente, the NHS has veryfew clinicians in formal leadershiproles. For senior doctors, theoperation of the current ClinicalExcellence Awards Scheme will bestrengthened – to reinforce proposalsin this chapter to drive qualityimprovement. New awards, and therenewal of existing awards, willbecome more conditional on clinicalactivity and quality indicators; andthe Scheme will encourage andsupport clinical leadership. Thescheme will also become moretransparent, with applications beingpublicly available. The profession willbe involved in developing andintroducing these amendments.In making national awards, theindependent Advisory Committee onClinical Excellence Awards (ACCEA)will have regard to advice from theNational Quality Board and the NHSLeadership Council.39. Finally, leadership is not just aboutindividuals, but teams. Successfulorganisations are led by successfulBoards. We will immediatelycommission a new developmentprogramme for trust boards throughthe NHS Chief Executive and the newNHS Leadership Council. In addition,we will encourage the developmentof Masters-level programmes whichare relevant to the health sector byproviding matched funding to SHAcommissionedprogrammes.Conclusion40. NHS staff make the difference forpatients and communities. It isthrough unlocking talent that wewill achieve high quality care acrossthe board. Many of the featuresdescribed in this chapter already existin the best of the NHS, but notsystematically so.41. We seek to change that not bycentral control, but by freeing NHSstaff and organisations to make theright decisions. Therefore, we willextend and improve existing reformssuch as NHS foundation trusts andpractice based commissioning.Through these changes, healthcareprofessionals will be not justpractitioners, but partners andleaders.
6High quality work inthe NHSSupporting NHS staff to deliver highquality careNursing sister and her young patientat Brune Medical Centre Gosport,Hampshire
High Quality Care For All – NHS Next Stage Review Final Report696High quality work in the NHSSupporting NHS staff to deliver high quality care1. To encourage staff who commissionand provide NHS services to take upnew opportunities and freedom, wemust ensure they can benefit fromsupportive working environments.High quality work means welldesigned,worthwhile jobs, supportfor learning and development, inhigh quality workplaces, with NHSstaff being respected for the caringand compassionate nature of theservices they provide.2. There has been significant changeover the past decade. Pay andconditions have been made fairer.This was an almost silent revolutionin making sure that the NHSrecognises and rewards the talentsof all its staff. Significant workforcecontracts were changed, inpartnership with the professions.There was an unprecedentedinvestment in education and trainingthat saw the largest expansion in thenumbers of doctors, nurses, andother clinicians for a generation.3. The service is no longer a singlenational employer – staff involved inNHS services are employed by theirrespective organisations, and the firststeps to improving the quality ofwork must always be taken locally.Nevertheless, there are two issuesthat we face nationally and requirenational solutions:• High quality workplaces. We willbe clear about what we expect ofone another, what staff can expectof NHS employers, and takepractical steps to improve thequality of workplaces.• High quality education andtraining. Working in partnershipwith professional representatives,we have developed proposals toimprove the system of workforceplanning, commissioning and theprovision of education andtraining. The key features aredescribed here, with the technicaldetails in a separate documentNHS Next Stage Review: A HighQuality Workforce publishedalongside this report. Educationand training also extends toensuring that NHS managers havethe skills they require.High quality workplaces4. I know from experience that workingin the NHS can sometimes befrustrating, and I have heard thatmessage over the course of theReview. The great strength of theNHS is that we are all part of thesame system. This should mean thatwe are all able to work effectivelytogether for the benefit of patients.Too often, however, when NHS workcuts across organisations the needs
70 6: High quality work in the NHS6of patients are not put first. There is atendency to put the perceived interestof the organisations first, and to shirkresponsibility for patients. There alsoremains an infuriating ‘not inventedhere’ resistance to adopting newways of working that can improvepatient care.5. That is why we need to be clearabout what it is that we stand forand what we expect of one another.NHS-wide values transcend individualorganisations. They are a greatstrength but we do not often talkexplicitly about them. Over the pastyear, we have carried out extensivework to identify and understand thevalues of patients, the public andNHS staff. These values are whatpatients, staff and the public tell usthey stand for. They are included inthe draft NHS Constitution.The NHS values have been derivedfrom extensive discussions with staff,patients and the public. They are:• Respect and dignity. We valueeach person as an individual,respect their aspirations andcommitments in life, and seek tounderstand their priorities, needs,abilities and limits. We take whatothers have to say seriously. We arehonest about our point of viewand what we can and cannot do.• Commitment to quality of care .We earn the trust placed in us byinsisting on quality and striving toget the basics right every time:safety, confidentiality, professionaland managerial integrity,accountability, dependableservice and good communication.We welcome feedback, learn fromour mistakes and build on oursuccesses.• Compassion. We find the time tolisten and talk when it is needed,make the effort to understand, andget on and do the small things thatmean so much – not because weare asked to but because we care.• Improving lives . We strive toimprove health and wellbeing andpeople’s experiences of the NHS.We value excellence andprofessionalism wherever we findit – in the everyday things thatmake people’s lives better as muchas in clinical practice, serviceimprovements and innovation.• Working together for patients .We put patients first in everythingwe do, by reaching out to staff,patients, carers, families,communities, and professionalsoutside the NHS. We put the needsof patients and communitiesbefore organisational boundaries.• Everyone counts. We use ourresources for the benefit of thewhole community, and make surenobody is excluded or left behind.We accept that some people needmore help, that difficult decisionshave to be taken – and that whenwe waste resources we wasteothers’ opportunities. Werecognise that we all have a part toplay in making ourselves and ourcommunities healthier.
High Quality Care For All – NHS Next Stage Review Final Report716. These values are the best of the NHSand should inform and shape all thatwe do. The NHS-wide values are notexclusive – they can and should sitside-by-side with the particular valuesin any individual organisation,supporting and reinforcing oneanother. But they should guide ourbehaviour when working acrossorganisations in the system. Living upto their letter and spirit should lead tohigher quality workplaces and betterservices for those who use the NHS.7. We believe that being clear aboutour values should help ensure highquality work. But staff are rightlykeen to know the practical differenceswe will make too. In the NHSConstitution we will therefore makefour pledges to all NHS staff, fromthe porter to the community nurse,the medical director to the chiefexecutive. The NHS will strive to:• Provide all staff with well-designed,rewarding jobs that make adifference to patients, their familiesand carers, and communities.• Provide all staff with personaldevelopment, access to appropriatetraining for their jobs, and linemanagement support to succeed.• Provide support and opportunitiesfor staff to keep themselveshealthy and safe.• Actively engage all staff indecisions that affect them and theservices they provide, individuallyand through representatives. Allstaff will be empowered to putforward ways to deliver better andsafer services for patients and theirfamilies.8. Just as the quality of care needs to bemeasured and published, the sameapproach should apply to the qualityof work. That is why we have agreedwith the Healthcare Commission thatstaff satisfaction will be an indicatorin the annual evaluation of NHStrusts and NHS foundation trusts.9. We will empower staff to hold theiremployers to account for theinvestment they make in learning anddevelopment. We will require everyorganisation that receives centralfunding for education and training toadopt the Government SkillsPledge, 103 to nominate a member ofthe board to be responsible, and topublish its annual expenditure oncontinuing professional developmentso that present and future employeescan make choices that are moreinformed.10. We will support staff with easieraccess to the tools they need to dotheir jobs. We will establishmystaffspace as a convenient, onestopportal for all staff. Through itthey will be able to access the newNHS Evidence knowledge portal andget information on what high qualitycare looks like and how to deliver it,tailored to their own professionalexpertise and interests. They will alsobe able to access information on103 http://inourhands.lsc.gov.uk/employersSkillsPledge.html
72 6: High quality work in the NHS6performance against the NHS qualityframework, their own personal staffrecords, their credentials, and a log oftheir learning and development. NHSMail will be there too. Mystaffspacewill give all NHS professionals betteraccess to the information they needto deliver excellent patient care.High quality education and training11. High quality care for patients is anaspiration that is only possible withhigh quality education and trainingfor all staff involved in NHS services.They provide care in a changinghealthcare environment. New roles areemerging. New technology ischanging the way they work. Patientsand the public, quite rightly, haveincreasing expectations ofpersonalised care. Workforceplanning, education and trainingneeds to change to enable staff torespond more effectively and flexiblyto this dynamic environment.12. The focus needs to be on the roles,education and training and careerspaths that will enable the NHS todeliver their visions for quality care. Wehave worked in partnership with all theprofessions and the service and manyothers to identify the changes that areneeded to map out a bright future.The issues highlighted here areaddressed comprehensively in the NHSNext Stage Review: A High QualityWorkforce published today alongsidethis report.Clearer roles13. For all health professions, we areworking in partnership with theirprofessional bodies, employers andother stakeholders to define theunique role and contribution of eachof them and how their roles arechanging across the pathways ofcare. From this starting point, andwith excellent quality of care as ourprimary, unifying goal, we will worktogether to define the skills andexpertise they require, and ensurethat these are underpinned byappropriate educational standardsand programmes.14. We will demonstrate how these roleslink with one another by establishingexplicit career pathways, which makecareer progression clearer, easier andmore flexible. We will also introducemodularised, accredited trainingpackages and strengthen educationalgovernance to ensure that all clinicalstaff have the opportunity to developtheir skills throughout their careersfor the benefit of patients, employersand their own career progression.15. We will also continue our work tomodernise clinical careers so that jobsand career opportunities continuouslyimprove.16. Foundation periods of preceptorshipfor nurses at the start of their careershelp them begin the journey fromnovice to expert. There will be athreefold increase in investment innurse and midwife preceptorships.These offer protected time for newlyqualified nurses and midwives tolearn from their more seniorcolleagues during their first year.
High Quality Care For All – NHS Next Stage Review Final Report73A locally led approach17. Our approach to reforming workforceplanning and education mirrors thatfor the provision of high quality care– a belief that quality is best achievedby devolving decision making to thefrontline in an environment oftransparency and clear accountabilitiesand where the role of educationcommissioner and education providerare clearly separated. We will ensurethat the workforce is able to meetthe needs of patients by developingworkforce elements of service plans,using the eight pathways of care ofthe Review as the basis for identifyingwhat patients need, now and inthe future.18. The new system will requireleadership and management ofworkforce planning and educationcommissioning throughout the NHS.This approach requires a stronger andmore constructive partnership with allprofessions. That is why we areestablishing new professionaladvisory bodies to enable theprofessions to contribute to strategicworkforce development at all levels.They will bring a single coherentprofessional voice to advise on howbest to achieve our vision of the highquality education and training thatunderpins high quality care forpatients.19. We will establish an independentadvisory non-departmental publicbody, Medical Education England(MEE), by the end of this year, toadvise the Department of Health onthe education and training ofdoctors, dentists, pharmacists andhealthcare scientists which needs tobe planned nationally. MEE nationallywill be supported by similar advisorybodies in every NHS region. Together,they will provide scrutiny and adviceon workforce plans and educationcommissioning strategies to ensurethat the NHS has the right quantityand quality of doctors, dentists,pharmacists and healthcare scientistsfor the future. We will work with theother professions to decide whatother national advisory boards arerequired, recognising the contributionof the diversity of professional roleswithin multi-disciplinary team todeliver effective evidence-based care.20. The national and local professionaladvisory bodies and the widerhealthcare system will be supportedby a Centre of Excellence, which,from April 2009, will provide objectivelong-term horizon scanning, capabilityand capacity development forworkforce planning functions,and the development of technicalplanning assumptions. It will alsoenable capacity and capability tomake the system work.Fair and transparent funding21. We are reforming the funding ofeducation and training to make itfairer, more transparent and ensurethat it is used for the purpose forwhich it is intended. It is for thosereasons that we will replace thecurrent historical fundingarrangements for the Medical
74 6: High quality work in the NHS6Professional Education and Training(MPET) budget with a tariff basedsystem where the funding follows thetrainee. These arrangements willreward quality, promote transparencyand protect investment in educationand training. With clarity about theresources dedicated to education andtraining, education commissionerswill be empowered to hold providersof that education and training toaccount, also taking into account the‘voice’ and choices of trainees.22. Nationally, we will seek to extendapprenticeship opportunities in theservice – recognising that healthcaresupport staff – clinical and nonclinical– are the backbone of theservice. We will therefore double ourinvestment in apprenticeships overthe next four years, and continue towork with trade unions and Skills forHealth to identify the appropriateuse of apprenticeships within eachclinical career framework, and innon-clinical roles.23. 60 per cent of staff who will deliverNHS services in 10 years time arealready working in healthcare. Weneed to make sure that they are ableto keep their skills and knowledge upto date so that they can provideservices that meet the changingneeds of both patients and localcommunities. Continuingprofessional development (CPD) isrightly the responsibility of individualemployers. Some do this well, butthis is not always the case 104 . Wetherefore intend to strengthen thearrangements to ensure staff haveconsistent and equitableopportunities to update anddevelop their skills.24. These and other changes set out inNHS Next Stage Review: A HighQuality Workforce will ensure thatwe have a system for workforceplanning, education and training thatwill be sustainable for the long term.Staff will have clearer careerframeworks and be able to makeinformed careers choices. Employerswill have a stronger voice inworkforce planning and educationcommissioning and provision and amore flexible workforce. Patients willreceive high quality care delivered byhighly trained staff and plannedaround their needs. The public willreceive better value for money fromnational education resources.Support for managers25. NHS management includes boththose who have clinical backgroundsand those who do not. Regardless ofwhether they have a clinical or nonclinicalbackground, managers andfrontline clinicians must forge astrong partnership, sharing successesor setbacks. In all cases, managersmust be involved in the core businessof clinical practice, helping,supporting and challenging cliniciansto deliver the best possible care for104 Although standard, consistent information ontraining is very difficult to obtain due to thevariety of approaches organisations take inbudgeting for training.
High Quality Care For All – NHS Next Stage Review Final Report75patients. This means ensuring thatsystems work effectively, whetherthey be patient flows, communitydisease management, theatreoperations or commissioning services.26. Support already exists to helpmanagers develop these skills.Indeed, the existing programmes formanagement development are oftenapplauded. These include the awardwinningManagement TraineeScheme (MTS) for graduates, theGateway scheme for individuals fromsectors other than health, and theBreaking Through scheme thatsupports black and minority ethnicpeople that wish to pursue careers inNHS management. Although theMTS welcomes applications fromqualified clinicians who wish tobecome full-time managers, atpresent there is no dedicated schemefor clinicians wishing to develop theirmanagement and leadership skills.27. Therefore, we will establish a newprogramme to equip and supportclinicians in leadership andmanagement roles. It will be calledthe ‘Clinical Management for Quality’programme. It will be dedicated tothose clinicians leading clinicalservices lines, with a particular focuson clinical directors and leaders inprimary care who are runningpractice-based commissioning orintegrated care organisations.managers meet high professionalstandards every day, a very smallnumber of senior leaders sometimesdemonstrate performance or conductthat lets down their staff, theirorganisations and the patients thatthey serve. We do not believe afull-blown system of statutoryprofessional regulation – akin to aGeneral Medical Council – would beproportionate at this time, but theDepartment will work with theprofession, the NHS and otherstakeholders to ensure that there arefair and effective arrangements toprevent poorly performing leadersfrom moving on to other NHSorganisations inappropriately. Whilean enhanced Code of Conduct formanagers will underpin this, we willconsider whether more effectiverecruitment procedures or a moreformal system of assuring suitabilityfor future employment would providemore effective and proportionatesafeguards.29.Conclusion30. Just as patients deserve high qualitycare, so NHS staff deserve highquality work. If frontline staff aregoing to focus on improving thequality of care provided by the NHS,they need the right workingenvironments and the right trainingand education.28. As responsibility is devolved to thelocal NHS, there will be greaterscrutiny of managers. Whilst theoverwhelming majority of NHS
7The first NHS ConstitutionSecured today for future generationsNewborn baby and her mother atChelsea and Westminster Hospital,London
High Quality Care For All – NHS Next Stage Review Final Report777The first NHS ConstitutionSecured today for future generations1. The NHS belongs to the people.It is there to improve our health,supporting us to keep mentally andphysically well, to get better whenwe are ill and, when we cannot fullyrecover, to stay as well as we can.It works at the limits of science –bringing the highest levels of humanknowledge and skill to save lives andimprove health. It touches our livesat times of basic human need, whencare and compassion are whatmatter most.2. To provide high quality care for all,the NHS must continue to change.But the fundamental purpose,principles and values of the NHScan and must remain constant.Setting this out clearly, along withthe rights and responsibilities ofpatients, the public and staff, willgive us all greater confidence to meetthe challenges of the future on thebasis of a shared understanding andcommon purpose.3. That is why in my interim report Icommitted to exploring the meritsof introducing a Constitution for theNHS. As a result of the work of thisReview, I am now convinced thatthere is a strong case for introducingthe first NHS Constitution.The case for a constitution4. An NHS Constitution will:• Secure the NHS for the future .The Constitution will set out clearlythe enduring principles and valuesof the NHS, and the rights andresponsibilities for patients, publicand staff.• Empower all patients and thepublic. Patients already haveconsiderable legal rights in relationto the NHS, but these are scatteredacross different legal instrumentsand policies. Some are obscure;many people are not aware ofall of their existing rights. TheConstitution will empower allpatients by summarising all existingrights in one place.• Empower and value staff . NHSservices are provided by over1.3 million staff. Those staff areour most important resource.For the NHS Constitution to bean enduring settlement, it needsto reflect what we are offeringto staff: our commitment toprovide all staff with high qualityjobs along with the training andsupport they need.
78 7: The first NHS Constitution7• Create a shared purpose,values and principles. As theNHS evolves, a wider range ofproviders, including those fromthe third and independent sectorsare offering NHS-commissionedservices. Patients expect thatwherever they receive their NHSfundedtreatment, the samevalues and principles should apply.All organisations are part of anintegrated system for the benefitof patients. That is why we willset out the purpose, principlesand values for the NHS in theConstitution. We propose thatall organisations providing NHSservices are obliged by law to takeaccount of the Constitution in theirdecisions and actions.• Strengthen accountabilitythrough national standards forpatients and local freedoms todeliver. The NHS is held toaccount nationally throughParliament, even though servicesare delivered locally. TheConstitution is an opportunityto clarify and strengthen bothnational and local accountability. Indiscussions with patients, publicand staff, we have received a clearmessage that they are committedto the NHS as a national system,paid for out of general taxation;from which they can expect certainstandards of care and access. Thedraft NHS Constitution thereforemakes clear what people canexpect from the NHS no matterwhere they live.How the Constitution was developed5. The NHS Constitution that we arepublishing in draft today has beendeveloped in partnership withpatients, public, staff and a numberof experts.6. During this extensive programmeof development, engagement andresearch we heard that: 105• To qualify as a Constitution, thedocument needed to be shortand enduring• The Constitution should beflexible and not hold the NHSback in terms of its ambitions forimproving the quality of care• For the Constitution to bemeaningful it must have bite,with means for enforcement andredress, not just warm wordsor aspirations• There was no appetite for a‘lawyers’ charter’, and concern thatwe should avoid fuelling litigationOur first NHS Constitution7. The draft NHS Constitution nowsets out in one place the purpose,principles and values of the NHS,and the rights and responsibilities ofpatients, the public and NHS staff.105 This included a literature review conducted by theLondon School of Hygiene and Tropical Medicinelooking at international experience; ElizabethClery, Trends in Attitudes to Health Care 1983 to2005: Report based on results from the BritishSocial attitudes Survey; a series of discussionevents with patients, the public and staff; andmeetings with leading experts.
High Quality Care For All – NHS Next Stage Review Final Report798. It reaffirms the commitment toa service which is for everyone,based on clinical need and not anindividual’s ability to pay.9. As well as collecting togetherimportant rights for both patientsand staff, it sets out a number ofpledges which reflect where theNHS should go further than the legalminimum. Each right or pledge isbacked up by an explanation, in theaccompanying Handbook to the NHSConstitution, on how they will beenforced and where to seek redress.10. We intend to legislate, as soon asParliamentary time allows, to require:• All NHS bodies and private andthird sector providers providingNHS services to take account of theConstitution in their decisions andactions• Government to renew the NHSConstitution every 10 years, withthe involvement of the patientswho use it, the public who fund itand the staff who work in it11. The Handbook to the NHSConstitution will be refreshed atleast every three years. As well assetting out the legal basis for allof the rights, it sets out how theperformance management andregulatory regime of the NHS willensure that the pledges in theConstitution are delivered.Accountability in the NHS12. The NHS remains a national healthservice, funded through nationaltaxation. It is right, therefore, thatit should be the Government thatsets the framework for the NHS andis held accountable in Parliamentfor the way that it operates. Theremust be a continuous thread ofaccountability through the system tothe Government of the day; and it isfor that reason that the Governmentbelieves that calls for an independentNHS board, which would remove theNHS from meaningful democraticcontrol, are misplaced. Moreover,the NHS has just come through aperiod of re-organisation. We donot believe this is the right time toimpose further top-down changeto structures. What matters more isthat there should always be clarityand transparency about who takeswhat decisions on our behalf. That isthe assurance that the Constitutionwill provide.13. The Constitution improvesaccountability by making clear:• What individuals have a right toexpect from the NHS• The principles by which decisionswill be made• Who is responsible for whatthrough a ‘statement ofaccountability’ to be publishedalongside the final version of theConstitution
80 7: The first NHS Constitution714. We encourage PCTs to experimentwith how they can improve theway they give and take accountof local views, within the currentlegislative framework. Many PCTsare already doing this, workingwith local communities and partnerorganisations to come up withgovernance arrangements thatincrease their responsiveness in away that best fits their local needs:Consultation process15. The NHS belongs to us all. TheConstitution is designed to reflectwhat matters, whether to patients,public or members of staff. It istherefore vital that the formalconsultation builds on the processso far.16. We will therefore create aConstitutional Advisory Forumthat will bring together leadingrepresentatives from the patient,clinical and managerial communities,to oversee the consultation process.The Forum will work with the NHSto lead a process of engagement inevery region of England, and reportkey messages back to the Secretaryof State. It will be co-chaired by DavidNicholson, the NHS Chief Executive,and Ivan Lewis, the sponsoringMinister.
High Quality Care For All – NHS Next Stage Review Final Report81
8ImplementationMaintaining the momentumAn advanced practitioner assessesmammograms at the NightingaleBreast Screening Centre, Manchester
High Quality Care For All – NHS Next Stage Review Final Report838ImplementationMaintaining the momentum1. This Review has shown that there isenormous enthusiasm and energythroughout the NHS for achievingthe vision set out in this report.The ambitious plans set out in everyNHS region will be challenging toimplement but in each case willimprove services radically for patients.2. I am keen that the pace should notdrop. While change of this magnitudewill not happen overnight, we shouldconstantly strive to achieve highquality care for patients and thepublic. This chapter sets out howthis will happen.Leading local change3. The Review as a whole hasexemplified the process I believe willdeliver these changes as effectivelyas possible. At its core has been thedevelopment of visions in every NHSregion. We should now back localleaders – clinical and managerial –to deliver them.4. I know that in each region, strategichealth authorities (SHAs) are alreadyworking with primary care trusts(PCTs) to discuss proposals locally andensure that the views of NHS staff,patients and the public are taken intoaccount. In many cases change isalready happening and patients arefeeling the benefits.5. By Spring 2009, each PCT will publishits strategic plan, setting out a fiveyearplan for improving the healthof people locally. These plans willput into practice the evidence-basedpathways of care at the heart ofeach region’s vision. They will showa strong emphasis on partnershipworking between PCTs, localauthorities and other partners (public,private and third sector – includingsocial enterprise) to ensure that localhealth and wellbeing needs arebetter understood and addressed.Enabling local change6. Centrally, we will enable localimprovements in three ways.• First, we will ensure that thefunding is there to deliver thechanges. The Department ofHealth will later this year makefinancial allocations to every PCTfor the next two years. This willgive PCTs clarity about the moneythey have to invest in improvingthe health of their populations.• Second, we will publish an NHSOperating Framework in Octoberthis year to set out the enablingsystem that will deliver this Review.Before then, the NHS ChiefExecutive and I will meet with staffacross the NHS to discuss how toensure this document bestsupports the delivery of PCTstrategic plans.
84 8: Implementation8• And third, we will ensure that, asthe Department of Health developsthe policy proposals described inthis report (via legislation, wherenecessary), it does so in partnershipwith the NHS and stakeholders toensure that the benefits we haveall identified are fully realised.This will include Equality ImpactAssessment wherever appropriate.Where a comprehensive evidencebasedoes not yet exist, we willalso commission a programme ofindependent evaluation to improvelearning and ensure transparencyand public accountability. 106Conclusion7. It has been a privilege to lead theNHS Next Stage Review. I amdelighted that thousands of peoplehave taken part in the process andhave seized the opportunity to shapean NHS fit for the 21 st century.8. The priorities they have identified,together with the steps set out in thisfinal report, represent an ambitiousvision, one focused firmly on thehighest quality of care for patientsand the public. I challenge everyonewho works in and with the NHS todeliver it for the benefit of this andfuture generations.106 This will achieve the goal of a close dialoguebetween policy-makers and researchersadvocated in N. Black. Evidence based policy:proceed with care. BMJ. 2001 Nov 17:323(7322): 1187.
Published by TSO (The Stationery Office) and available from:Onlinewww.tsoshop.co.ukMail, Telephone Fax & E-MailTSOPO Box 29, Norwich, NR3 1GNTelephone orders/General enquiries 0870 600 5522Order through the Parliamentary Hotline Lo-Call 0845 7 023474Fax orders: 0870 600 5533E-mail: email@example.comTextphone: 0870 240 3701TSO Shops16 Arthur Street, Belfast BT1 4GD028 9023 8451 Fax 028 9023 540171 Lothian Road, Edinburgh EH3 9AZ0870 606 5566 Fax 0870 606 5588The Parliamentary Bookshop12 Bridge Street, Parliament Square,London SW1A 2JXTSO@Blackwell and other Accredited Agents