After 60 years, the NHS has signalled the end of cheap-and-cheerful, any-colour-so-long-as-it’s-black healthcare.

That’s about 30 years after manufacturing, retailing, telecommunications and the rest of the service sector embraced the idea that the customer is king, and what he (or she) wants is quality service. But let’s not quibble.

Lord Darzi’s review sets quality of care first, and everything else a distant second. Almost all the detailed changes he proposes are designed to raise standards.

Doctors and hospitals will be measured by the quality of care they deliver, and rewarded accordingly. Patients will be asked their opinion, and other more specific outcome measures - such as how many patients die - will be used to determine just how good their care has really been.

In general practice, the Minimum Practice Income Guarantee (MPIG) will go. Income will instead depend more on the Quality and Outcomes Framework, which measures what GPs do, rather than what their historic income has been.

Hospitals that deliver a classy service will be paid more than the rest, under the tariff that determines the cost of every procedure. Everybody will publish annual Quality Accounts, equivalent to their yearly financial accounts.

Primary Care Trusts will be forced to pay for treatments passed cost-effective by the National Institute for health and Clinical Excellence, and Strategic Health Authorities given a legal duty to encourage innovation.

Patients will get enhanced rights of choice over where they are treated, harnessing market power to raise standards.

The theme is clear. “This whole report is about quality,” Lord Darzi said. David Nicholson, chief executive of the NHS, said: “Quality is to become the organising principle of the NHS”.

But can the service deliver? Historically, it has always valued shifting large numbers of patients through their episodes of care as a greater good than ensuring they were as well-treated as medical knowledge makes possible. Central targets enshrined this principle, to the fury of clinicians.

Lord Darzi now claims to have listened to the clinicians, and shaped his report from what he heard. “This is not a document pulled together by a small group of people in the Department of Health” insisted Mr Nicholson, as if we might possibly have suspected it.

At issue is whether the levers are strong enough to bring about change. The document assumes that quality improvement will have no victims. But better quality can only come about by chasing out bad: that means eliminating poor GPs, closing failing hospital services, or even entire hospitals. Otherwise there won’t be the money to reward the good.

These changes are painful. Lord Darzi envisages them being driven locally, but his chosen instrument, the primary care trusts, are weak reeds. Hitherto most of them have been easily managed by ingenious GPs and popular local hospitals. Most patients don’t even know what PCTs are: and if PCTs try to do anything tough, they are easily characterised as “NHS bosses” cutting services.

There are also some spectacular gaps in the promises the documents make. The NHS Constitution - a “declaratory document” said Lord Darzi, for which read the usual well-meant pieties - makes only one new promise, that of universal patient choice.

But when pressed, the Health Secretary, Alan Johnson, seemed unsure how that would apply to popular GPs whose lists are full, and Lord Darzi disabused anybody of the idea that it means you could choose a particular surgeon - for instance, him.

In his team of colorectal surgeons at St Mary’s Paddington, all were equally good, he insisted. But if choice doesn’t mean the right to choose a particular GP or a particular consultant, what does it mean?

And if you can’t really choose, how can bad practitioners be driven out to make way for better ones? Competition is a bloody business, as a million corner-shops run out of business by the supermarkets can attest.

Lord Darzi’s report lacks any acknowledgement of this. It simply envisages an NHS aspiring ever upwards to unimagined levels of quality and care, leaving nobody behind: no victims, no bankruptcies, no tears. Life isn’t like that.

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