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In October 2007, Lord Darzi published his interim report - Our NHS, our future - which set out the purpose and scope of a wide-ranging review of the NHS in England.

The intention is to redesign how care is organised, building on the success of the NHS to date but redefining the relationship with patients by providing more personalised services, including choice. Building leadership capacity, particularly among clinicians, is seen as essential to ensuring effective high quality services. Four major themes have emerged.

Fair - equally available to all, taking full account of personal circumstances and diversity.
Personalised - tailored to the needs and wants of individuals, especially the most vulnerable and those in greatest need, providing access to services at the time and place of their choice.
Effective - focused on delivering the best outcomes for patients.
Safe - giving patients and the public confidence in the care they receive.
An additional and important change is that whilst the Department of Health sets out policy and priorities centrally, the aspiration is that service redesign and implementation is to be led through strategic health authorities and more locally through primary care led commissioning. The nine SHAs have each convened eight groups, to develop the following clinical pathways.

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

These groups comprise individual senior clinical or social care staff, most of whom also hold management roles in their workplaces. There are not many geriatricians on these groups. Work is well advanced. A variety of events such as a clinical summit in November and consultative workshops in January have been used to refine the pathways. Each SHA’s vision for healthcare is due to be published in the Spring. 
To provide additional support for the SHA work, the Darzi team at the DH have set up eight national groups to consider cross cutting themes: quality, innovation, leadership, workforce, information, systems and incentives, primary and community care and a constitution for the NHS. All these will contribute to the final report to be published in June 2008, setting out the vision for the next decade. Details of the national and local groups and events, and Lord Darzi’s blog can be found at www.ournhs.nhs.uk/local/

What about older people?
Since older people are the main users of health and social care, criticism could be aimed at the review for not identifying their needs as a specific theme. On the other hand, the issue of ageing and health should be right there in all work streams except maternity and children’s health. In one of the Prime Minister’s early speeches in 2008, celebrating 60 years of the NHS, he stated - “One of the main challenges that the NHS faces in the coming decades is that of high quality, cost effective care for increasing numbers of older people”. What is needed is to make sure that this reality is competently and adequately reflected in each of the SHAs’ visions for healthcare, and the details as they emerge from this.

This is a challenge but also an opportunity for geriatricians and their multidisciplinary colleagues. Many of us have been frustrated before when trying to promote the importance of the specialist old age approach to the modern NHS, but there is a real opportunity now to bring our clinical and service, expertise from the field into this review. This is not about preserving our services, as they now are, as things around us change and threaten what we have built. It has to be about reshaping our services but more important than this is to export the lessons we have learnt into the wider clinical world.

For example, centralising surgical specialties coupled with a model of decentralised post acute care simply won’t work if assessment and clinical management isn’t designed to meet the clinical needs of older people. This must include revolutionising the traditional pre-operative assessments to incorporate identifying those at risk for frailty syndromes such as delirium, incontinence and immobility, and changing clinical care accordingly. Likewise the emergence of urgent care centres, maybe in tandem with services to avert acute admissions needs comprehensive geriatric assessment at the heart. We all know how patchy this is in current intermediate care.

This review is predicated on the conviction that patients aspire to see improvements in access, better experience of care with dignity and greater personal control, and receiving the right care in a timely fashion through better integration. Embedding the necessary “old age” skills in these clinical pathways is vital if this is to be achieved. And if not, then the service redesign threatens to be an expensive failure.

Lord Darzi has promised an improved vision for the NHS through enhanced clinical engagement. We should use this to push at the doors and make sure that neither we nor the needs of older people become marginalised in the new NHS.

Deborah Sturdy
Nurse Advisor Older People, Department of Health

Finbarr C Martin
Medical Adviser Older People, Department of Health

BGS Newsletter, March 2008
Issue 15 ISSN 1748-6343 15