SEVEN POINT MANIFESTO FOR THE NHS SUPPORTING AND ADDING TO LORD DARZI'S NEXT STAGE REVIEW AND FINAL REPORT

JULY 2008 – DR RICHARD TAYLOR FRCP MP

Most of these points were made in a speech, subject to a time limit, in the House of Commons on 22 July 2008, Hansard cols. 733-4, and offered as potential vote winning material for the major political parties to consider at their conferences.

1. ABOLISH PRESCRIPTION CHARGES

These are unfair and can never be made so without great complications. The Government review has been struggling with the issue for many months and is still not ready to report. The loss of revenue reported to be £450 millions could be made up by better prescribing, for example the Government's own paper "Better Care, Better Value Indicators" or, in addition and in my opinion essential, by a small hypothecated tax increase for those earning over £100,000 per annum.

2. THE FOUR Cs OF QUALITY

CARE – safety, avoidance of errors, consistent use of evidence based protocols for treatment of common illnesses.

COMPASSION – dignity and kindness.

COMMUNICATION – between staff and patients and their families and between all hospital staff and primary care staff. 
(ref. BMJ 2008;337:a664)

CONTINUITY OF CARE – difficulties in hospitals because of the Working Time Directive have not been overcome everywhere – continuity in general practice is threatened by the Darzi GP-led health centres if they are not integrated fully with established local GPs.

Where any of these quality issues are not met, until the NHS has agreed on quality measurements, the only available quality measure (perhaps stronger than patient surveys) is the number and severity of complaints. For high profile and initial investigation such complaints should be made to the constituent's MP who should then take them up with the commissioners and providers of the service. Financial rewards or penalties would focus efforts on improvement.

3. COMPETITION – obligatory reading "The NHS: 'losing my religion'" by Richard Smith former editor of the BMJ (ref. J R Soc Med 2008: 101: 332-333) now working in the private sector. This explains how he reluctantly discarded his lifetime belief that the NHS could do everything required of it to a high standard. He bemoans this and Governments' of both colours responses in frustration that have been frequent structural changes which have compounded the problems. 

Equally reluctantly I have had to recognise that where small parts of the NHS could produce excellence the whole is like a super tanker and cannot be turned around in time to avoid disaster. One possible answer is regulated competition. 

Richard Smith writes in the same article "There would be regulated competition, because, much as we might bemoan the fact, competition is one of the few drivers that can consistently deliver higher quality and lower costs". 

To me regulated competition means tendering on a fair, open, level playing field where tendering is open to NHS and non-NHS providers. Commissioners would have to provide a detailed specification for the service to be provided including rules for how services are to be provided and the staff skill mix expected. This might remove providers interested only in profit by uncontrolled delivery of services by less trained and skilled members of staff.

4. FOUNDATION TRUST STATUS FOR ALL PROVIDER ORGANISATIONS INCLUDING PRIMARY CARE, HOSPITAL AND MENTAL HEALTH CARE

Foundation trusts can keep their own surpluses and have greater independence from the Department of Health and Strategic Health Authorities and greater public and patient involvement through their membership. Savings could be put into quality awards or any other locally agreed priority..

5. ACCELERATE THE WORK OF NICE 

– as planned in the Darzi review as this is surely the best method of tackling the issue of NHS top-up fees.

6. MAKE PATIENT AND PUBLIC INVOLVEMENT IN HEALTH REAL 

The new local involvement networks (LINks) must be actively and meaningfully involved in health care commissioning decisions and work closely with health overview and scrutiny committees which in some areas need strengthening. See the report of the Local Government Association Health Commission report "Who's accountable for health?"

7. HEALTH CARE RATIONING

This has to be faced by all and not skirted around with euphemisms like prioritisation. 

Smith again writes "I wouldn't compromise on universality, and high quality must remain an aspiration. It's thus comprehensiveness that must go, as it has done, but I would like to see much more scrutiny and debate around a basic package.......... an evidence-based package stripped of the doubtful and the excessive could be better for all of us....." 
In the same journal Maynard and Bloor write "The final recurring theme, present throughout the last 60 years and no doubt the next 60, is the thorny question of rationing health care." 
Also "The future of rationing health care will provide a key battleground for the NHS."

We cannot avoid this vital debate which would supplement the work of NICE and with the independence of Foundation Trust providers allow local priorities to be considered alongside NICE guidance with full participation by patients and the public.

R.T.

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