- David Oliver, consultant in geriatrics and acute general medicine
- davidoliver372{at}googlemail.com
Follow David on Twitter: @mancunianmedic
One week after Labour’s general election victory Wes Streeting, the new health and social care secretary, announced a rapid diagnostic review of the state of the NHS, to be led by Ara Darzi—a professor of surgery and a health minister in the last Labour government. Streeting simultaneously announced a working group to produce a 10 year plan for healthcare, reporting next spring.1
Darzi’s Independent Investigation of the National Health Service in England was published on 12 September.2 His remit was to include social care or the wider health of the nation only “in so far as they impact on the NHS.” The report excludes detailed policy recommendations, although it does list seven key themes to inform the development of the 10 year plan. These include greater staff and patient engagement, better productivity in hospitals, “hardwiring financial flows” to support a shift from secondary to community care, and a “tilt towards technology.” It also emphasises the value of good NHS managers at the operational coalface, while criticising the overly complex patchwork of central agencies and regulators.
Darzi concludes that the NHS is “in serious trouble” and that “the first step to rebuilding public trust and confidence” is to be “completely honest about where it stands.” His report is damning about access and long waiting times across primary care, elective care, urgent and acute care, mental healthcare, and community services. All are considerably worse than they were in 2015, let alone in 2010 when Labour last left office. Darzi cites the impact of long waits on patient experience and outcomes and on overcrowded emergency departments, which he admits are “in an awful state.”
Performance concerns
The greatest concerns expressed by the public in surveys and focus groups are around waiting times, GP access, and NHS workforce pressures.34 Darzi does conclude, however, that many services deliver good care when patients eventually get them.
His concerns about performance go beyond access and waiting times. He highlights our poor cancer outcomes in relation to other developed nations. Worsening waiting times for initial assessment, investigation and diagnosis, and starting treatment are mentioned as a factor in this. He also mentions deterioration in urgent care for people with acute coronary syndrome and acute stroke, with lengthening times from the hospital door to treatment, major variations in access to revascularisation or brain imaging, and stalling improvement in outcomes.
Much of this mirrors Labour’s priorities during its previous period in office—when it had inherited a health service with long waits and poor access. It prioritised tackling these as an area of major public concern. It also focused on improving care and outcomes in common causes of mortality such as stroke, heart disease, and cancer, using national programmes and frameworks.56
Darzi highlights the wider determinants of preventable ill health, along with inequalities such as housing, incomes, and worsening unemployment.78 More people are living more of their lives in poor health. And more of us have multiple long term medical conditions—increasingly, not just over 65s but also young people and working age adults.
This very much mirrors the focus in the chief medical officer’s 2023 annual report.9 The rising number of people with long term multimorbidity places ever greater demands on the NHS. It shifts the necessary emphasis away from a single organ focus with reactive, episodic care towards a need for more continuous, integrated, and preventive care.
False economy
In analysing how the NHS got into its current unhealthy state, Darzi pulls no punches. Of course, the pandemic played a part. Beyond this, he’s scathing about the needless disruption and repeated re-disorganisation caused by the Health and Social Care Act 201210 and the work involved in undoing this—in turn, giving the service little long term stability or confidence.1112 Remember that before the 2010 election the NHS had drastically reduced waiting times across all services, with targets hit consistently and with staff and patient satisfaction at record highs.6
Darzi is equally clear about the effects of a sustained period of austerity under the coalition and subsequent Conservative governments, historically low annual funding uplifts in real terms, and serious underinvestment in capital spending on health facilities and equipment when compared with other nations. Capital budgets are repeatedly raided to prop up day-to-day operational revenue—a short term false economy, which Darzi concludes contributes to falling productivity among NHS providers and worsening staff morale and retention.
Although Darzi is now a politically independent peer, the politics behind the report matter. This is a chance, at the start of a new parliament, to set out the scale of the challenge facing services, before the new Labour government can reasonably attract any blame for the current problems. And it’s an opportunity to remind ourselves that the last time Labour was elected it drove sustained improvements in a service facing similar challenges, and that the decline since then has happened on the Conservatives’ watch. Darzi sets out realistic and tempered expectations, arguing that transformation will take several years, with no quick fix in sight.
Unflinching
But the diagnosis in Darzi’s report requires treatment in the form of concrete actions. Streeting13 has so far responded with generic rhetorical pledges about “three big shifts” to prevention, community care, and digital health. But he provided no logistical or financial detail and ducked issues around social care and public health.
This week the prime minister, Keir Starmer, said in a speech at the King’s Fund14 that he welcomed the report’s findings and endorsed its principles, but he made it clear that little new money will come from the Treasury without major improvements in NHS productivity (especially in hospital care)—despite Darzi specifically highlighting financial underinvestment. The gains under Labour governments from 1997 to 2010 partly rested on record real terms annual funding uplifts to the NHS, which won’t be forthcoming this time.
We wait to see any detailed logistical delivery plans, including those for increasing productivity and value per pound spent. But you can’t solve a problem without acknowledging and describing it—and, while all information in the report was already in the public domain, Darzi has done this superbly in one single, clear, and unflinching report.
