ࡱ>  objbj %hh1gNVV8y|T?.pe"@@@>>>>>>>$A$D>"@>?$$$6>$>$$_;O=pò p<>$?0T?<6D{"D,O=DO=p@$'@@@>>5$^@@@T?D@@@@@@@@@V _:  HIGH QUALITY CARE FOR ALL, THE NHS NEXT STAGE REVIEW FINAL REPORT BMA SUMMARY Background The NHS Next Stage Review, Our NHS, Our Future, was announced in July 2007 and was a wide-ranging review of the NHS in England, both at a local and national level. It was led by Lord Darzi, Parliamentary Under Secretary of State at the Department of Health. A first interim report was published in October 2007 and a second in May 2008; BMA summaries of these reports are available at the following website address:  HYPERLINK "http://www.bma.org.uk/ap.nsf/Content/DarziReviewsNational" www.bma.org.uk/ap.nsf/Content/DarziReviewsNational A BMA position statement setting out our concerns over some aspects of the review process as a whole and the proposals made in the early stages of the review is available at the following website address:  HYPERLINK "http://www.bma.org.uk/ap.nsf/Content/Darzipositionstatement" www.bma.org.uk/ap.nsf/Content/Darzipositionstatement The final review report was published on 30 June 2008; it is available at the following website address:  HYPERLINK "http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825" www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825 This is a BMA summary of the intentions and recommendations of the report. CHAPTER 1 CHANGE LOCALLY LED, PATIENT-CENTRED AND CLINICALLY DRIVEN This chapter gives an overview of regional review processes and findings in the SHA visions and clinical pathway group reports. Some key, shared themes arising from the regional reviews: Preventing ill health; Ensuring timely access; Providing convenient care closer to home; Improved diagnostics; Giving more control to patients integrating care around patients needs, personal budgets for complex long term conditions (LTCs); Ensuring care is effective and safe specialised centres, cleanliness/infection-free; High quality care comparison of performance of different providers; Personal care; and Innovation partnerships with higher education institutions and private sector, greater collaborations between primary, secondary and social care. CHAPTER 2 CHANGES IN HEALTHCARE AND SOCIETY Six challenges listed: Higher and rising expectations; Demand driven by demographics i.e. ageing population; Health in an age of information and connectivity abundance of information on treatment and diseases available, need to ensure that information accessed is reliable; Changing nature of disease unhealthy lifestyles leading to growing prevalence of COPD, diabetes and depression; Advances in treatments best practice constantly changing, cost implications; and Changing health workplace. The NHS must respond by improving the quality of care it provides (paragraph 29). CHAPTER 3 HIGH QUALITY CARE FOR PATIENTS AND THE PUBLIC Helping people to stay healthy We willstrive to accept and implement every recommendation for screening and vaccination programmes that the relevant national expert committees [Joint Committee on Vaccination and Immunisation (JCVI) and National Screening Committee (NSC)] make (paragraph 9). Vascular health checks for all aged 40-74 from 2009 in GPs, pharmacies and community clinics. Nationwide reduce your risk public information campaign to be launched simultaneously. By 2012, three million people to be checked each year. Pharmacies have key role to plan in providers of prevention services. [Paragraphs 12-13]. PCTs to commission comprehensive wellbeing and prevention services, in partnership with local authorities, with the services offered personalised to meet the specific needs of their local populations (paragraph 14). Six key goals: tackling obesity; reducing alcohol harm; treating drug addiction; reducing smoking rates; improving sexual health; and improving mental health. Establishment of a Coalition for Better Health, with a set of new voluntary agreements between the government, private and third sector organisations on actions to improve health outcomes. Initial focus will be on combating obesity (paragraph 15). Vision for Primary and Community Care (report to be published separately) some headlines (paragraphs 20-23): Support family doctors to play a wider role in helping individuals and families to stay healthy by amending Quality and Outcomes Framework (QOF) to include better incentives; New resources to be invested in areas worst affected by obesity and alcohol-related ill health; Introduction of integrated Fit for Work services in primary and community care, to help people to return to work. Includes musculoskeletal services and psychological therapies. Work with GP representatives to develop a fairer funding system (i.e. phase out of MPIG) (paragraph 28). Empowering patients: more rights and control over health and care Extended choice in primary and community care, patients to have a greater choice of GP practice (paragraph 27). Continued development of NHS Choices website to include more information on services offered by GP practices, opening times, views of local patients and performance against quality indicators. Easier electronic registration with GP practices through NHS Choices (paragraph 31). Department of Health nationally to consider costs and benefits of new 3-digit telephone number for urgent, unplanned care once introduced in some regions following SHA reviews. Further details to be set out later this year (paragraph 32). Personal care plans for those with LTCs to be offered over the next 2 years. Plans are to be agreed with the individual and a named, lead professional and to be regularly reviewed (paragraphs 34-25). Educational role of NHS Choices website to be expanded (paragraph 37). Payments to hospitals conditional on quality of care, measured by safety (cleanliness and infection rates), clinical outcomes, patient experience and patients views on outcomes of treatment (or patient-reported outcomes measures [PROMs]). The Commission for Quality and Innovation (CQUIN) scheme will form part of commissioning contracts and will be an overlay to Payment by Results system. National tariff uplift to be reduced in 2009-10 to allow funds for commissioners to pay for improved outcomes. In 2009-10, providers to be rewarded for providing data. From 2010-11, payments will reward outcomes. Flexible scheme to suit local circumstances and subject to independent evaluation. [Paragraphs 39-41]. National pilot programme for personal health budgets to be launched in early 2009 followed by rigorous evaluation. Budgets to be held on patients behalf in most cases. Programme to be voluntary and tailored support will be given to those with personal budgets. All NHS principles to be upheld, comprehensive service, free at the point of use; no denial of treatment and appropriate accountability. [Paragraphs 42-44]. Ensuring access to the most effective treatments All patients to have a right to NICE-approved treatments and drugs where judged by their doctor as of benefit. Patients should expect rational local decisions on funding of new drugs and treatments with open and honest explanation if the NHS decides not to fund them (paragraph 48). Improvements to the process will lead to NICE issuing majority of appraisal guidance within a few months of a new drugs launch (paragraph 49). CHAPTER 4 QUALITY AT THE HEART OF EVERYTHING WE DO Quality includes the following (paragraph 2): Patient safety infections or other avoidable harm such as drug errors; Patient experience compassion, dignity and respect given to patients; and Effectiveness of care mortality, complication or survival rates and patient-reported outcomes measures (PROMs). Seven steps to improve quality. Bring clarity to quality NICE to be expanded to set and approve more national quality standards, including relevant National Service Frameworks, from 2009. NICE to manage spread of knowledge through a new website, NHS Evidence, containing clinical and non-clinical evidence and best practice. NICE to establish a fellowship programme. Measure quality First set of integrated, national quality indicators to be announced in December 2008 for acute services. National metrics to be developed through discussion with patients, the public and staff. From 2009, quality framework for community services to be developed and piloted. [Paragraphs 9-11]. Department of Health to work with professional bodies, specialist societies and universities to develop a wider range of local metrics (paragraph 12). Development of Clinical Dashboards to present selected national and locally developed quality measures to inform daily decisions taken by clinical teams. Three pilots underway. [Paragraphs 12-13]. The goal is for every provider to systematically measure, analyse and improve quality. Providers to develop their own quality frameworks combining national indicators with local ones (paragraph 14). Development of a new strategy to develop the QOF, including independent and transparent review of indicators. Aim to reduce number of organisational or process indicators and refocus resources on new indicators of prevention and clinical effectiveness. Explore scope to give PTCs greater flexibility to select quality indicators, from a national menu, that reflect local health improvement priorities. [Paragraph 15]. Publish quality performance From April 2010, all providers working for or on behalf of the NHS to publish Quality Accounts. These are reports on the quality of their services looking at safety, experience and outcomes. Information based on these accounts will be on NHS Choices website (paragraph 17). Care Quality Commission (CQC) to validate provider (and commissioner) performance against national indicators agreed with the Department of Health. CQC to publish assessment of comparative performance and an annual report to Parliament, assuring that information about quality of care is reliable. [Paragraphs 17-18]. Department of Health to work with other countries to agree internationally comparable quality measures (paragraph 19). Recognise and reward quality improvement National tariff/Health Resource Groups (HRGs) to be improved from April 2009 to recognise complexity of care and support innovation (paragraph 21). More information on the 4th version of the tariff online:  HYPERLINK "http://www.ic.nhs.uk/our-services/standards-and-classifications/casemix/hrg4" www.ic.nhs.uk/our-services/standards-and-classifications/casemix/hrg4 Projected tariff uplifts and efficiency gains to be set on a multi-year basis aligned with future Spending Reviews and PCT allocation cycles to help providers plan ahead (paragraph 22). Mental health national currencies available for use from 2010-11 to allow comparison and benchmarking of mental health services (paragraph 23). Raise standards We will put a strong clinical voice at every level in the NHS (paragraph 24). Support clinical teams and clinical directors to develop through peer review, continuing professional development (CPD) and professional revalidation (paragraph 25). An accreditation scheme for GP practices being developed by the RCGP is being piloted and, if appropriate, will be adopted nationally by 2010 (paragraph 25). Stronger clinical engagement in commissioning required. This must go beyond practice based commissioning (PBC) and professional executive committees (PECs) to involve all clinician groups in strategic planning and service development (paragraph 26). PCTs responsibility. The World class commissioning (WCC) programme will achieve this through a feedback survey from clinicians, quarterly PBC survey, PBC governance arrangements, the 5-year strategic plan and interviews between the PCT board and a panel of independent experts, one of whom will be a clinician. [Paragraphs 26-27]. By April 2009, appointment of new, dedicated SHA Medical Directors, responsible for overseeing implementation of local clinical/SHA visions and providing medical leadership to NHS organisations in the area. To work alongside regional directors of public health and closely with PEC chairs. Professional accountability to the NHS Medical Director at the Department of Health. [Paragraph 29]. Establishment of SHA Clinical Advisory Groups to support senior clinical leadership teams within SHAs. Competitive appointment (paragraph 30). SHAs to establish formal Quality Observatories to inform local quality improvement efforts. Information to be made available through NHS Choices and NHS Evidence websites (paragraph 32). Establishment of a National Quality Board to provide strategic oversight and leadership on quality. Will oversee work to improve the quality metrics and advise the Secretary of State on quality in England. First report to be published by June 2009 drawing from the output of reviews published by the CQC. The board will be chaired by the NHS Chief Executive and Membership will include representation from national statutory bodies. [Paragraph 33]. Safeguard quality/intelligent regulation CQC will enhance the role of independent regulation (see paragraphs 35-36). Stay ahead/pioneering NHS Health Innovation Council (HIC) established (in October 2007, following interim report of Next Stage Review) to champion innovation for the NHS. NICEs expanded role will provide clearer standards leading to commissioners disinvesting in superseded treatments (paragraph 39). A Best Practice Tariffs programme will pay for costs of best practice rather than average cost. From 2010-11, the programme will focus on four high-volume areas where there is significant variation in practice: cataracts; fractured neck of femur; cholecystectomy; and stroke care. Department of Health to discuss proposals with clinicians and issue further information later this year. Programme will be evaluated and if successful, will be expanded in future years (paragraph 40). SHAs to have new legal duty to promote innovation and will have access to new regional innovation funds, following successful application to an independent expert panel. New prizes for innovations that directly benefit patients and the public for the local NHS. [Paragraph 41]. Health Innovation and Education Clusters to be established to bring together partners across primary, community and secondary care, universities and colleges, and industry. Clusters will run joint innovation programmes, pioneer new treatments and models of care. Over time, clusters may be commissioned to provide postgraduate education and training of all healthcare professionals. Clusters will not be defined or imposed nationally. Applications for assigned status and funding to be submitted by December 2008 for assessment by an expert peer review process. [Paragraphs 42-45]. Academic Health Science Centres (AHSCs announced in the interim report in October 2007) to bring together health and academic partners to focus on research, teaching and patient care. Will compete internationally with other centres. Criteria to be defined by the Department of Health; international panel of experts to award status and review centres that have self-designated AHSC status. No pre-defined number; 5-10 organisations have expressed an interest so far. Governance models will be looked at on a case-by-case basis. Department of Health will work with interested organisations to develop the optimal governance model over the next year. [Paragraph 46-49]. CHAPTER 5 FREEDOM TO FOCUS ON QUALITY Importance of team work emphasised (paragraphs 1-3). A new professionalism will give clinicians the opportunity in the future to be (a) practitioners (b) partners (with a responsibility towards the service and working closely with others) and (c) leaders (both formally and informally). Greater freedom for the frontline Acute, mental health and ambulance trusts Rate at which existing NHS trusts achieve foundation trust status to be accelerated. Commitment to the ambition that in the future, hospital care will be provided by NHS foundation trusts (paragraph 8). To extend these freedoms, Department of Health will explore options including social enterprises and community foundation trusts. For some providers, such as high secure units, foundation trust status not appropriate, but similar freedoms will be given to such organisations performing well (paragraph 9). Community services Where PCTs and staff set up social enterprise organisations, transferred staff to continue to benefit from NHS Pension Scheme if wholly NHS-funded (paragraph 15). Staff right to request to set up social enterprises. PCTs will be obliged to consider requests. PCT board to approve business case, if successful, PCT to support development of social enterprise and award it a contract for an initial period of up to 3 years (paragraph 16). NHS commissioners Under the World class commissioning (WCC) programme, where PCTs demonstrate improvement on health outcomes, they will be given greater freedom over the priorities they set and methods and people they employ. These freedoms to be set out in the autumn. [Paragraphs 17-18]. PCTs free to take the name of their locality e.g. NHS Blackpool (paragraph 19). Department of Health to establish a list of independent sector organisations that can help PCTs to develop the capabilities of their management boards (paragraph 20). Creating a new accountability As national targets are achieved, they become minimum standards. New national challenges will be met through minimum standards and by national priorities being reflected in local commissioning. No additional top-down targets beyond the minimum standards (paragraph 21). New approach to accountability through openness on quality of outcomes achieved for patients (paragraph 22). No national targets for quality, but quality will need to be measured by providers (as per chapter 4) (paragraph 23). Later in 2008, Department of Health to complete standard, but flexible, contract for community services (paragraph 24). Intention to move away from block contract funding for community services (paragraph 24). Assurance system for PCTs/NHS commissioners (as part of the WCC programme) to be implemented by March 2009; first results formally published in March 2010 (paragraph 25). Empowering staff Stronger support to practice based commissioning (PBC) in the form of incentives for a broader range of clinicians to be involved in the process, including community clinicians and specialists working in hospitals (paragraphs 28-29). Pilot new integrated care organisations (ICOs) that bring together health and social are organisations. Based on the registered patient lists for groups of GP practices. Proposals will be invited shortly (paragraph 30). Fostering leadership for quality Core elements of leadership: (a) vision (b) method and (c) expectations (paragraph 31). Department of Health to explore how to reflect skills and demands of leadership in undergraduate curricula for all medical and nursing students. Leadership development to be an integral part of modernising careers programmes for other healthcare professionals (paragraph 33). SHAs and Health Innovation and Education Clusters (see chapter 4, paragraphs 42-45) to be encouraged to establish Clinical Leadership Fellowships (paragraph 34). New Leadership for Quality Certificate. Three levels of operation; level 1 for members of clinical and non-clinical teams interested in becoming future leaders; level 2 for leaders of team and service lines; and level 3 for senior directors (e.g. medical, nursing, operations) (paragraph 35). NHS Leadership Council to be established, chaired by the NHS Chief Executive, overseeing leadership across healthcare including the top 250 leaders, who will get close support in development, mentoring and career management. Council to have focus on standards, including overseeing the new certification, development of curricula and assurance. Dedicated budget with ability to commission development programmes. [Paragraphs 36-37]. The Clinical Excellence Awards Scheme (for senior doctors) will be strengthened. New awards and the renewal of existing awards will be more conditional on clinical activity and quality indicators. Scheme will support clinical leadership, become more transparent, with applications being publicly available. Profession will be involved in developing and introducing these amendments (paragraph 38). The independent Advisory Committee on Clinical Excellence Awards will take advice from the new National Quality Board (see chapter 4) and the new NHS Leadership Council (paragraph 38). Department of Health to commission a new development programme for trust boards through the NHS Chief Executive and the new Leadership Council. Will encourage development of Masters-level programmes by providing matched funding to SHA-commissioned programmes (paragraph 39). CHAPTER 6 HIGH QUALITY WORK IN THE NHS High quality workplaces NHS values set out and should guide behaviour (paragraphs 5-6): Respect and dignity; Commitment to quality of care; Compassion; Improving lives; Working together for patients; and Everyone counts (resources used for the benefit of the whole community, wasting resources wastes others opportunities). Four pledges in the (draft) NHS constitution to provide all staff with (paragraph 7): Well-designed, rewarding jobs that make a difference. Personal development, access to training and line management support. Support and opportunities for staff to stay healthy and safe. Engage staff in decisions that affect them and the services they provide, individually and through representatives. Staff satisfaction to be an indicator in the annual evaluation of NHS trusts and foundation trusts (Healthcare Commission/CQC) (paragraph 8). Every organisation that receives central funding for education and training to adopt the Government Skills Pledge, to nominate a member of the board to be responsible and to publish its annual expenditure on continuing professional development (paragraph 9). High quality education and training Proposals on workforce planning, education and training are set out in detail in a separate Department of Health publication, NHS Next Stage Review: A High Quality Workforce, published alongside the main review report. A BMA summary of this report will be available in due course. The report is available online:  HYPERLINK "http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085840" www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085840 Key recommendations are as follows (paragraphs 11-24): Threefold increase in investment in nurse and midwife preceptorships to offer protected time for newly qualified nurses and midwives to learn from senior colleagues during first year. Establishment of new professional advisory bodies to enable the professions to contribute to strategic workforce development at all levels. Establishment of an independent advisory non-departmental public body, Medical Education England (MEE) by end of 2008. MEE will advise the Department of Health on education and training and will be supported by similar bodies in each SHA region. Establishment of a Centre of Excellence by April 2009, to support workforce planning functions. Medical Education and Training (MPET) budget to be replaced by a tariff-based system. Doubled investment in apprenticeships. Strengthen arrangements to ensure staff can access to continuing professional development. Support for managers Managers and frontline clinicians to forge strong partnerships (paragraph 25). New Clinical Management for Quality programme to be established dedicated to clinicians leading clinical service lines, in particular clinical directors and leaders in primary care running PBC or integrated care organisations (paragraph 27). Department of Health to work with the profession, the NHS and other stakeholders to ensure arrangements to prevent poorly performing leaders/NHS managers moving to other NHS organisations inappropriately. Enhanced Code of Conduct for managers. Department will consider whether more effective recruitment of a more formal system to ensure suitability of future employment is necessary. [Paragraph 28]. CHAPTER 7 THE FIRST NHS CONSTITUTION A consultation on a draft NHS constitution has been launched separately. The consultation can be accessed online:  HYPERLINK "http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085814" www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085814 The (draft) NHS constitution sets out the purpose, principles and values of the NHS as well as the rights and responsibilities of patients, the public and NHS staff (paragraph 7). All NHS bodies and private and third sector providers providing NHS services will be legally bound to take account of the Constitution in their decisions and actions (paragraph 10). Government will renew the Constitution every 10 years, with the involvement of patients, public and staff (also to be set in legislation) (paragraph 10). Government to continue setting the framework for the NHS, maintaining overall authority and accountability, rather than establishing an independent NHS board (paragraph 12). Constitution Advisory Forum to be established to oversee consultation process. Will comprise representatives from the patient, clinical and managerial communities and chaired by NHS Chief Executive and the sponsoring Minister (Ivan Lewis) (paragraph 16). CHAPTER 8 IMPLEMENTATION PCTs to publish 5-year strategic plans by Spring 2009 putting into practice the SHA visions (paragraph 5). Financial allocations to PCTs later in 2008 for the next two years to help with planning (paragraph 6). Publication of an NHS Operating Framework in October 2008 to set out the system that will deliver the review proposals (paragraph 6). Department of Health to develop the proposals in partnership with the NHS and stakeholders (paragraph 6).     British Medical Association bma.org.uk PAGE  PAGE 1 %GHSTU_`     I K L M  $ P Q zo]zPzEzhpOhCJaJhYKhpO0JCJaJ#jhYKhpOCJUaJhpOhpOCJaJjhpOCJUaJh oCJaJhpOCJaJhhCJaJhpOhpO5CJaJhpO5CJaJh\hCJaJh\hFH\5CJaJh65CJaJh\h5CJaJh5CJaJ h5jh5UmHnHuHTU`   b c d e l & F]gd$ x]gd$&dP]gd$]gd$Q ] = > Q      ! % 4 ? Z [ a obWOhm~CJaJhbh*CJaJh+hb0JCJaJ#jh+hbCJUaJhbhbCJaJhbCJaJjhbCJUaJh*CJaJhhpOCJaJhFH\hpOhCJaJhYKhpO0JCJaJjhpOCJUaJ#j]hYKhpOCJUaJhpOhpOCJaJhpOCJaJa b c d e Pjw%&'bcdym_h oh45>*CJaJh oh4>*CJaJh o>*CJaJh o5CJaJh4h o5CJaJh5CJaJh4CJaJh$CJaJhKlCJaJhbCJaJh oCJaJhbhb5CJaJhbh o5CJaJhCJaJh*CJaJh*CJaJhpOCJaJ#aHa$%&c & F]gd$ x]gd$]gd$&dP]gd$ & F]gd$cd=YZSTr & Fx]^`gdo & F]gd$ x]gd$]gd$HQV_fEXYmST_y{&0;<DESTq㫟~h$h o5CJaJh$h $U5CJaJh5CJaJh$h\5CJaJh\CJaJh oCJaJhCJaJh $Uh $U5CJaJh $UhM5CJaJhMCJaJh $UCJaJh4CJaJh $Uh45CJaJ1(-123`fn6лssh\huhu5CJaJhuhuCJaJhuh\5CJaJh\h\CJaJh o>*CJaJh Gh oCJaJh GCJaJh\h G5CJaJh$5CJaJh4>*CJaJh oh o>*CJaJh oh4>*CJaJh $UCJaJh$h\5CJaJh\CJaJhuCJaJ 23wx!!/#0#a#b#$$%%&dP]gd$]gd$ & F]^`gdo67vwx~H !!!!!!!!"".#0#`#ûλtl`lllTh8bh8b>*CJaJh^f(h8b5CJaJh8bCJaJh8bh8b5CJaJh8bh^f(5CJaJh^f(CJaJhhcxG5CJaJh0r~CJaJh oCJaJhcxGhuCJaJhcxGCJaJhcxGhcxGCJaJhcxGhcxG5CJaJhu>*CJaJhuCJaJhuhuCJaJhu5CJaJ`#a#b#y####$$%%%M%N%O%m%{%|%}%'&M&W&X&&&&&&&&&&׻㛫}rfZhm~hzN>*CJaJhm~h'zn>*CJaJhm~h6CJaJhm~h*CJaJhbCJaJh0r~h0r~CJaJh0r~CJaJh4CJaJhzNCJaJhKlCJaJh~,h45CJaJh*CJaJhCJaJh~,h~,5CJaJh~,CJaJh$CJaJh8bh4>*CJaJ%%%N%O%}%%&&&&&&&'' (( & F ]^`gd$ 8]^8gd$ & F  ]` gd$ & F]gd$ x]gd$]gd$&dP]gd$&&&&&'p'r''''''( ( (('(v(w((()%)7)8)))))**e+f+w+++øڌڌtڌڌhhh\h'znh65CJaJh6h65CJaJhMAh3O5CJaJh6h3O5CJaJh6CJaJhm~hpO>*CJaJhm~h'zn>*CJaJhm~hzN>*CJaJhzNhFH\CJaJhhzNCJaJh3OhzN6CJaJh3OCJaJhzNCJaJh'zn5CJaJhzNhzN5CJaJ$(8)9)))**e+f+ - -'-(-@.A.////(0)011^2_22 & F ]^`gd$]gd$+b,, - - -'-9--///(0)0u000001Q1S1T1U111111]2^2_2223㷯zm㷯eYhm~h3w>*CJaJhzNCJaJh+h3w0JCJaJ#jh+h3wCJUaJh3wh3wCJaJjh3wCJUaJh3wh3wCJH*aJh3wCJaJh3wh3w5CJaJh CJaJh'znh'zn5CJaJhm~h'zn>*CJaJh'znCJaJh6CJaJh'znh65CJaJ"2233Q3R3334466s8t89999;;;;<<<< & F ]^`gd$]gd$33P3Q3333!4445 515855555556666*7t8888889399999999*:0:<:販ܩ衕ȍumhMCJaJh9whKTs5CJaJh#hKTs5CJaJhKTsCJaJhKTsh u5CJaJh uCJaJh=;5CJaJh=;h=;CJaJh=;hq/CJaJh)CJaJhq/heU5CJaJhq/hq/5CJaJhq/CJaJheUCJaJh3wCJaJ*<:Z:^::;1;;;;;<<<<6<X<<<<<==!=5=T=<>@>?K?d?q????2@Z@@AABB:C DVDwwoh8CJaJhm~hm~5CJaJhgMhgM5CJaJhVhV5CJaJhgM5CJaJhgMCJaJhm~CJaJhgMhV5CJaJhVCJaJhm~hV>*CJaJhm~hM>*CJaJhKTsCJaJh9wCJaJhMCJaJhEsCJaJ+<<<2=3=>>,>A>N>O>??1@2@~BB#E$E%E&EPEREEE&dP]gd$ & F]gd$ x]gd$]gd$VD$E%E&EOEPEQERE`EiEEEwFFFFFFLGGHH7HVHHHHKI]IIIIIJJJJJȴȨȗ{{sgssgss_shMACJaJh=?h=?5CJaJh=?CJaJh=;CJaJh=;h{X5CJaJhL8CJaJh{XCJaJhP>*CJaJhPhP>*CJaJh=;hP5CJaJhgMCJaJhPCJaJhPhm~5CJaJhPhP5CJaJh$CJaJh*CJaJh8CJaJ%EvFwFFFFFGGHHHHIIJJJJKKLLLLLLMM]gd$J_KLLO_OOOOOGPVPYPiPjPkP~PPPXQQ8RXRRRRRSϾ㶌xxxppdhphp5CJaJhpCJaJh<&h<&5CJaJh<&CJaJh<&>*CJaJhMA5CJaJhMAhMA5CJaJh=;hMA5CJaJhMACJaJhkqCJaJhZ>*CJaJhZCJaJhZh=?5CJaJh*CJaJh=?CJaJh=?h=?5CJaJ'M_N`NNNQOROOOXPYPjPkPWQXQ7R8RYRZRRRSSkTlTUUHWIW]gd$SSS;TZT[TlTTUUVGWHWIWMWgWnWWWWWXYYYZZZZZZZ]^^ļ|sk_kh_Uh_U5CJaJh_UCJaJh_U>*CJaJh$CJaJh*CJaJhi:hi:5CJaJhxCJaJhi:CJaJhi:h=S5CJaJh=SCJaJh=CJaJhRCJaJh=hR5CJaJhp5CJaJhphp5CJaJhphpCJaJhpCJaJ"IWXXYYZZZZZZZZ2[G[f[r[[[\ \v\ & F]gd$ x]gd$&dP]gd$]gd$v\\\0]]]3^4^7_8_]_^_uavaaebbcJddd & Fx]^`gdo x]gd$]gd$ & F W]^`Wgd$^6_7_8_[_\_^_k__:`<`{`}`~````aaaarasatauavaaaaaebubbbbbºº®£‘yºqeZeqhn{htCJaJhn{ht5CJaJhn{CJaJh~)hCJaJhh~)0JCJaJ#jnhh~)CJUaJh~)h~)CJaJjh~)CJUaJhtCJaJh~)CJaJh=;h5CJaJhCJaJh>*CJaJh>*CJaJh_UCJaJhCJaJ#b7cWccdJdodddd e"e#e;eeeee~ff9g:gIghhhhh>h?h@hhhh&i(i)iٽ٩yn\#jqhh sCJUaJh sh sCJaJjh sCJUaJh sCJaJh 7h5CJaJh$CJaJh*CJaJhCJaJh 7h 75CJaJh 7CJaJhi#hi#5CJaJh~)CJaJhi#CJaJhn{CJaJhn{hn{5CJaJhn{hn{CJaJ$d"e#e:e;eee}f~fhhhh?h@hhiiCjDjjjkkDlEl&dP]gd$]gd$ & F]gd$)i*iiiiikEmFmGmHmdmfmmmmmn+nMndnno0o1o2o4o5o7o8o:o;o=odofoƾơƕyqmqmqmqmfbh=; h;>h=;h5hjh5hUhn{hn{CJaJhUCJaJh7}5CJaJh7}hU5CJaJhn{hn{5CJaJhn{5CJaJh&6[CJaJh*CJaJhn{CJaJh]f:CJaJh 7CJaJh sCJaJhh s0JCJaJjh sCJUaJ"ElEmFmGmHmemfmmm:n;nnn0o1o3o4o6o7o9o:oyqH8.g^N>^5ZW/eܯR͏̭}6πqSspQsW{|?Pڻ8iHhWuK5?){jVo.-&Yco)"5 ~kcGүd[\UgiFVjiocx+ᶮ_aӀ܇ 0!# PE~|h-,MzRSmB̧>* l27ĕɴ-?!IAfχh~/F}*>т0BiWyQN&֍jaj"zשɣk vѭѵZ\Fakd_|fYGu"J mt->XE0F]ĴB?#m 0[m{ "?JRYM:Bfg3C:G *k{r(ΏŠߌ_;dύhn+AkͿai3@M_7QR[h([\8?j~&MG[(VF]rǂIcyҵ/3¿ jW-gTXkT秥EJt0%lߺtS ]| %̗fY?cτZɩ6sRI'σZV{^15H}{5 o[_y6 ;ӧ}}U_{ Q_u]*\.B+ @ʌ0AW?5[_P?iK{qNT¿*%Sw4w'>/xj@4wLGu&Gލve ZO$x"<7>'oR9*9:y\0:߆>M E53ݘQO_o?~B"~(^Ԯ~Zj"_ ' ?t ??Oj_iךm3΁ 5xW}V&4<-eo-L-SZ)[Ww }_{+3Tn+()~ o`@?>'Y|fK/ECxcCOm_?Eߍ?)?[^xrBKwEX+ڗ$?zu7;ݺ3 ~BN jOYʅ$Y"ULu}_o~H>4Dc-":*|o:O6. 4p:f3!}eŖ\O=e.0$I=ȫ>n:NJ/2?ޣ׌n|9NJ/2?ޣ'W폃~ h~_Moj\B$i:Iw*3CW4) N[YӴh-MĊ|kr'SǾ)l\s6ӳhL 4gi||~6|eׅm_ nn.4o&~qb7W]ӝX卬ݾyh( ( ( (<=O, ᯌMhika&HTRaX~+|3i_UsiZjLl&猜dC_ 'kZ̵z'Mǭ\+%HX>d>~U_FF3_PȾ12a[ᇋ|uɥNeK^{Ar~SUǟ66666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH N`N Normal$a$ CJOJQJ_HaJmH sH tH DA`D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 4@4 Header  9r 4 @4 Footer  9r ``  Char Char$dxa$ CJOJQJ^JaJmH sH tH 6U@!6 pO Hyperlink >*B*phFV1F 3wFollowedHyperlink >*B* ph.)@A.  Page NumberHRH N+ Balloon TextCJOJQJ^JaJPK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] g 5@MMMPQ a 6`#&+3<:VDJS^b)ifoo8:;>?ABDFHIKMORSUXc%(2<EMIWv\dEleoo9<=@CEGJLNPQTVWLP=(T))XYrY`)aagXXXXXX5<@GIP!!l,R$ZÁQ84@(    S <A bma blue logo4#" `?B S  ?g%&t`[,[ a[X b[lZ c[,X d[W e[W f[,V g[V h[Y i[V j[U k[U l[lU m[,U n[T o[T p[lT q[,T r[S s[S t[R u[,R v[,S w[lS x[lR y[R z[P )A S q E2-2--22844BGRj\g     - E V t I6-6--22;44BGRn\g 8*urn:schemas-microsoft-com:office:smarttagsdate9*urn:schemas-microsoft-com:office:smarttagsplace?*urn:schemas-microsoft-com:office:smarttags stockticker8 *urn:schemas-microsoft-com:office:smarttagsCityB*urn:schemas-microsoft-com:office:smarttagscountry-region  k 2008306DayMonthYear Z^|{$$Q(U(2-6-001 144,6;677::IIKKYY0g1g1g3g3g4g4g6g7g9g:g?@AAAABCCCCCDIJJCKlLLNN4OGO'RR4V6W~^J_L_r_``cCdee;fff-g1g1g3g3g4g4g6g7g9g:gMA GcxGgMzN3O $UeU&6[FH\5h'zn o sKTs u9wn{7}0r~t6==?x$cM<_Ui#8b\ 8)pOEsL m~3wKlMi:*4PRoUV{b R=SZ6~)=;{Xkq41g3g@8Qg@Unknown G* Times New Roman5Symbol3. * ArialK"Frutiger 45 Light7.  Verdana5. *aTahoma?= * Courier New;WingdingsA BCambria Math"1hrt&rt&:&fW4fW4!4dff 2qHX ?2!xx#NHS Next Stage Review: final reportSally Al-Zaidy Dr Anne Hicks,        Oh+'0 4@ ` l x $NHS Next Stage Review: final reportSally Al-Zaidy Normal.dotmDr Anne Hicks2Microsoft Office Word@G@`@,n@,nfW՜.+,D՜.+,P  hp|  BMA4f $NHS Next Stage Review: final report Title| 8@ _PID_HLINKSA4$"^ghttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085814 'Z ghttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085840 K] Mhttp://www.ic.nhs.uk/our-services/standards-and-classifications/casemix/hrg4 !_ghttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825 |c<http://www.bma.org.uk/ap.nsf/Content/Darzipositionstatement :http://www.bma.org.uk/ap.nsf/Content/DarziReviewsNational   !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdfghijklnopqrstuvwxyz{|}~Root Entry F0ݲData e1TablemDWordDocument%SummaryInformation(DocumentSummaryInformation8CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q